408887_Well Construction - GW1_20121024

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION #
1. L TITIA(1.0
vv - Contractor (Inyividuai) Name 4�-' ctim p )1/41
s!erriir;n
�Ira cor+nv ��� es
Stregt Address
re-0 n NC. czci (i
City or Town Zip Code
l-Wq
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#W
fONACIS Z6
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check A licable Box): Residential Water Supply CV
State
DATE DRILLED
TIME COMPLETED 66 AM ❑ PM
4. WELL LOCATION:
CITY: VCOUNTYHanover-
LAZkU etc) DC, � S�oCe �g'a i S/ 1
�1
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑ Valley ❑ Flat ❑ Ridg Other
LATITUDE 36
LONGITUDE 75
" DMS OR 3x.xxxxxxxxx DD
" DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL Fr
+�h� AIlad��S
Owner e
qaD,..__Lt:ElaaLD
Street Address
‘ki 1 I Al aiLl I
c
City or Town State Zip Code t-73
)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 1Q
b. DOES WELL REPLACE EXISTING WELL? YES NO 0
c. WATER LEVEL Below Top g of Casing: ZO FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 4-
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): METHOD OF TEST
l f. DISINFECTION: Type C'h1 (I Q.Amount
g. WAT ZONES (dxo
Top �". Bottorff"' Top
Top'" (,20 Bottom Top
Top Bottom Top
•
408887 8 8
Bottom
Bottom
Bottom
Thickness/
7. CASI G: Depth Diameter Weight M erial
Top 4 Bottom Ft. L.
�►�rl
Top Bottom Ft.
Top Bottom Ft.
8. GR UT: Depth
Top^" Bottom Ft.
Top . j Bottom A3 .Ft.
Top Bottom Ft.
M.terial
coq+-
Method
9, SCREEN: Depth fifi Diameter Slot Size M terial
UF
Top— Bottom " 17t, in, 10 in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Siz
Top Q Bottom— Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
12. REMARKS:
) hi I
ForFormation Description
eou�Cs� Sa��
ies-�� s-cod,c Icy
5And
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Scat 54or)
OCT 2 2012_
Information 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 COP THIS RECORD HAS BEEN
PROVI'ETO HE WELL • . ER.
SI RTIFIED WELL CONTRACTOR
DATE
SCidda_
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]
DL)If--FaK e1
Form GW-la
Rev. 2/09