396533_Well Construction - GW1_20110802

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
fl') a I I ei l fi 11;/13
Well Contractor Company Name
STR ET ADDRESS I� c �.Y C Q- l i t
DiAC9.6 er- 7
ity or Town S Zip Code
(� )- S qY 3Ci J
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) (�
STATE WELL PERMIT#(ir applicable) f (c,
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply K
DATE DRILLED lQ- (9 f 1
3
TIME COMPLETED i-Qf AM ❑ PM
3. WELL LOCATION:
CITY: Nlalf— k v 1 k I G COUNTY JJ\ I o %1
C 0-2,n \bocce. Rc
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, bp Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley Xlat ❑ Ridge ❑ Other
(check appropriate box)
Cam' f'.�5
LATITUDE 3
LONGITUDE 0 19 i 'i 4
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: 16GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this tom if not using GPS)
4. WELL OWNER OWNER'S NAME \
V��1C3.-u'(1
STREET ADDRESS t�`�L�l�r,
`
City or Tow State
Area code - Phone number
5. WELL DETAILS: 5 (-.)
a. TOTAL DEPTH:
�e\tuts
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO)e_.
c. WATER LEVEL Below Top of Casing: L-50 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS t 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): (i METHOD OF TEST r
gr...6167)
efi e?es
f. DISINFECTION: Type --if-1 Amount 1pT
g. WATER QZONES (depth :
From rb O To (n X From To
From"? `4 To q.n..' From To
From) la To From To
6. CASING: Thickness/
Depth, tr9Tg
UFromTo L-I, Ft. / '4..'"Weighlj f CH
From To Ft.
From To Ft.
7. GROUT:�*, Depth Material Method
From l J To 3!', Ft. I Affi{N ‘v 'T-,C) i ✓' .
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From .3o Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
in.
in.
in.
Material
Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
- I a
R5- :2C0'
11. REMARKS:
Formation Description
►-� K�.a� �ll a
LJ C SI c
LL6f-e
RECEIVED
2011
Information Processing Unit
DWQ/BOG
1 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.
77, iy 6 1-0
NATURE OF CERTIF ED WELL CONTRACTOR DATE
\`\- r1 fl u � 1 It
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. 1a
Rev. 7/05