390544_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # b 3 87
1. WELLCONTRACTOR:
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Well Contractor (Individual) Name
•DL en Li. \: s ci c \ Alt
( jWell rC�onttrractor Company ame �\
et:/e\r\C-ess t Addr
ity onowiL, .—(c) n , /� State Zip Code
Area code Phone number `� (�
2. WELL INFORMATION: t� r
WELL CONSTRUCTION PERMIT# \. V -- �5
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED lD - o t
TIME COMPLETED' Y2' t 0 AM 5CPM ❑
4. WELL LO ATION: I W^
CITY: Mbn✓� COUNTY \Arr1
(Street Name, Numbers, Community, Subdivision, Lot Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley gElat ❑ Ridge ❑ Other
LATITUDE Is -34" Q.19 `‘' DMS OR 3X.Xxxxxxxxx DD
LONGITUDE SO " 39' C9 «D " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 1J20r-S Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
I 5 \--\Ow\cS 1.,IQc•
Name
1 C
treet Address
CY\34("C--' M C_ c (I 9-
City r Town State Zip Code
Area code Phone number
6. WELL DETAILS: �^\
a. TOTAL DEPTH: `JV
b. DOES WELL REPLACE EXISTING WELL? YES :.• NO Lam'
c. WATER LEVEL Below Top of Casing: h2.5 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): `Q METHOD OF TEST IL.,K-
f. DISINFECTION: Type Airig Amount / /
tr
rV' `P `t4
g. WATER ZONES (depth):
Top 15 ' Bottom 16- ` Top Bottom
Top I 1 O\ Bottom 1tr5' Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth [ , Diameter Weight /a'terial
Top 0 Bottom 7 5 Ft. 6l p e102.5 HOC
C
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth , Material Method
Top 0 Bottom 3 c Ft. tlepulf 4 to p(/ 7Jpec(
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
in.
in.
in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom,
026
L6'/ 36
/60 / a06'
12. REMARKS:
7 ; FIVE J
if 07 2911
information Processing Unit
OVvn/sO'G
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.
SIG URE OFCERTIFIED WELL CONTRACTOR DATE
.704 iv r''l. 091.j.<
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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