405527_Well Construction - GW1_20120611

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2616-A
1. WELL CONTRACTOR:
iimmv S. Quinn
Well Contractor (Individual) Name
Quinns well irillina
Well Contractor Company Name
3242 Dotter$ hill rd.
Street Address
Pick Hill N.C. 28572
City or Town State Zip Code
( 252 ) 568-2380
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 25224
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply fig
DATE DRILLED 4-2-12
TIME COMPLETED 2-DM AM ❑ PM rit
4. WELL LOCATION:
CITY: maamolia COUNTY dualin
•
hwv- 117-s 1/2 mile on left from maanolia
(Street. Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope [Valley Ef Flat ❑ Ridge
LATITUDE 36
LONGITUDE 75
°
Latitude/longitude source: [ GPS
(location of well must be shown on a
this forrn if not using GPS)
5. WELL OWNER
.dose samuel zeppda
Owner Name
515 keliv rd.
(check appropriate box)
❑ Other
" DMS OR 3X.XXXXXXXXX DD
" DMS OR 7X.XXxxxXXXX DD
❑Topographic map
USGS topo map andattached to
Street Address
mount olive
City or Town
( 252 ) 550-0332
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 90
nCi
State
Zip Code
i g. WATER ZONES (depth):
: Top 75. Bottom 90 Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top +1 Bottom 80 Ft. 2"
Top Bottom Ft.
Top Bottom Ft.
A
Bottom
Bottom
Bottom
Thickness/
Weight Material
sc40 pvc
8. GROUT: Depth Material
Top 0- Bottom 20 Ft. bentonite
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 80 Bottom 90
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top 75 Bottom 90
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0 /12
12 /35
35 /74
74 / 75
7io
/
/
/
JUN 1.1 �
: 12. REMARKS:
Method
poored
Diameter Slot Size Material
Ft.2 in. 15 in. pvc
Ft. in. in.
Ft. in. in.
Size Material
Ft. med sand
Ft.
Ft.
Formation Description
sandy clay
y3llow sand
blue clay
rock
RECEIY-€b
JUN 2012
DiyilopriG
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO gr
c. WATER LEVEL Below Top of Casing: 32
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS + 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
FT.
•
e. YIELD (gpm): 20 METHOD OF TEST blowed
f. DISINFECTION: Type Glorine Amount 1 3" Dill
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.
4 4 -2-12
S NATUR F CE -TIFI • WELL CONTRACTOR DATE
Jimmy S. Quinn
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09