390553_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality s :` F FT; 5 6
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
111 S he't l ` 11;,N5
WellContractor
Com any Name ��1L` STREET ADDRESS �N—C l C Ai I i `-t J-
C'N Cl_r1 -\—�.. NC__, .� a @, ri
(10Nty orcTo7 Lci \ 4 Zip Code
J
Area code- Phone num er
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check ApplicableaBox): Residential Water Supply L
DATE DRILLED /6 / - b -/O
TIME COMPLETED /6 --/ 9 --/D AM 0
3. WELL LOCATION:
/
CITY: ! " / U /1% I U e
PME —
COUNTY U N t O r0
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
O Slope ❑ Valley at 0 Ridge 0 Other
(check appropriate box)
LATITUDE L1/4.5— �, �3 S
LONGITUDE I 0 A6 r i 61.5
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME Edt) :),,Soto
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS / a hS /9 . ex ilivriew54 an-)
( oruk e. /7), C Z?//6
City or Town State Zip Code
(9/C(i I - -'7 ( b
Area code - Phone number
5. WELL DETAILS: �� .
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? ��YES fi!--NO 0
c. WATER LEVEL Below Top of Casing: T g' FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ./46 METHOD OF TEST /Tr iK
f. DISINFECTION: Type /7" /J
g. WATER ZONES (depth):
Fromt3 To J 35 Rona 35 To
From / F.5 To a 3 0 From 3 85 To
From To From To
Amount
6. CASING:
Depth
To Ft.
To Ft.
To Ft.
From
Diam
F Q y� ‘3IAeter
From
From
-2y5
/00
Thickness/
Weight eri I
/; 5
7. GROUT: Depth , Material
From 0 To . 35 I�
Ft. ,n eivAiwi�
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10: DRILLING LOG
From To
O /6'
avl
o'Lu- /DC
yWb
11. REMARKS:
Material
Foq(neti Des io
6i?()to. v SA/q -e
/3 ‘). /4/
2 ,' Sig l'
..-I`N 07 2011
Inforrr,ation Processing Unit
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNA RE OF CERTIFIED WELL CONTRACTOR DATE
atip /'7, r74; 5
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 7/05