GW1--04459_Well Construction - GW1_20240730

;:yam E °ATf�`"N,, RESIDENTIAL WELL CONSTRUCTION RECORD
s t_ _ A North Carolina Department of Environment and Natural Resources-Division of Water Quality
;� y; o.
,' a,M,;,rx=' WELL CONTRACTOR CERTIFICATION # 5) 10 9 4-
1. WELLpiNTli. CTORiA F.DISINFECTION: Type:'_CIO A-1tit Amount/el a Z-
1 k t G prNtlii 0 i'y G.WATERR ZONES(depth): I
Well contractor(In ividual)Nae / From/ To / 2 I3 From To
Cl PmK `tl. P/rl /I i '1 1 W From To _ From To
Well Contractor Company Name j L 0 / , From To _ From To
STREET DDRESS 3 IA)ii i T (- P/W�- i`� 6. CASING: Thickness/
6 k.1 G.` L/,L a 7-3 3 3 d Depth -1 , Diamgte� Weight, Material
City or Town State Zip Code From To / 3 17 Ft y 2-11 •-4 � e-"
11, 3? 7 Ch/ From To Ft
Area code-Phone Number From To _ Ft
2. WELL INFORMATION: CD P r 7. GROUT:
SITE WELL ID#(if applicable) 11 I I J° — 1 Depth 3 1/7 / Material Metho
YFrom O To Ft i'afiL y�4
STATE WELL PERMIT#(if applicable) Y d i1 0�bg 7
From To _ Ft
DWQ or OTHER PERMIT If(if applicable)
From To _ Ft
WELL USE(Check Applicable Box);Residential Water Supply❑ 8. SCREEN:
DATE DRILLED a- 3 - �- / Depth Diameter Slot Size Material
TIME COMPLETED I '151 AM 0 PM[p/ From To Ft in. in.
From To Ft in. in.
3. WELL LOCATION: / ..
1 I l 5 I ^ From To Ft r in' t
CITY: 61CL'A VA1l-e,-' COUNTY (1 ✓.itr ✓ �r L�
I }} G 9. SAND/GRAVEL PACK: �f 7q
CY I c.c4 �"A)I.1 � "� L7 Depth 7 3 0 [v rial
(Street Name,Numbers,C¢mmunity,Subdivision,Lot No.Parcel,Zip Code) From To Ft
TOPOGRAPHIC/LAND SETTING: V Iri° ai. ��a"r,^,I; 5 Ufa
❑Slope El Valley 0 Flat idge ❑Other From To _ .a OCIi
(Check appropriate box) e, / From To _ Ft
LATITUDE 3 L/ er 7/ A7 10.DRILLING LOG
p From ToDescription
LONGITUDE ed r!m ©Z (3 11 0 — l/ /5'L,i, ,'-/ !O�.�fl
Latitude/longitude source: 0 GPS ❑Topographic map /_ ,/Q� J
(location of well must be shown on a USGS topo map and l _ ��/ v `'�� �r
Attached to this form if not using GPS) / S 7-3 / ~/%% Z i3/c c /`
<./ci7f i. LDa-)- -
4. WELL OWNER _i '
OWNER'S NAME BCt()l T l 5 k 0+ o ✓/,ii iiCki 0 -7 1
STREET ADDRESS bD SA (rt/fpinl '1) / 3 e/ZU 6 ze,1G 6, n �4.
6 l e_ Ua It= rue--- a S L 2.-7 riivr A.�IL--
City or Town State Zip Code
33Co - 4S7 /s &c)
Area code-Phone Number
5. WELL DETAILS: )
11. REMARKS:
A.TOTAL DEPTH: (2*- °
B.DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
>/ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTION IN ACCORDANCE WITH
C.WATER LEVEL Below Top of Casing: Vi/� FT. 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS RECORD HAS
(Use"+"if Above Top of Casing) / BEEN PROVIDED TO HE WELL O ER.
D.TOP OF CASING IS cu FT.Above Land Surface* / -v � Ac4:1"D'I---'1
J Z ` t c?7
*Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED W LL CONTRACTOR DATE
a variance in accord nce with 15A NCAC 2C.01 ,/1/-" M_ /.';,///i2,
E.YIELD(gpm): 3 1 METHOD OF TEST PRINTED NAME OF PERSON CONSTRUCTING THE WELL