408811_Well Construction - GW1_20121022

RESIJJ,ENTL4LWELL CONSTRUCTION RECORD
North Mina Department of Environment and .Naiurai Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
n /71
i/C alfd ; "
Well contractor Company Name
71/ Ve t v e
Street Address
144 v- 5 toil
cnyorTown
( 97 0 )_ 76) 2 6:
Area code Phone number
2. WELL INFORMATION: 6
WELL CONSTRUCTION PERMIT* Wi'O
2.9
! ,7/2 r
OTHER ASSOCIATED PERMIT#{tf applicable)
S(TE WELL ID #(ffappitoabte) .
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 9,'i5/i �
TIME COMPLETED it% 0 0 AM 0 PM
4. WELL L TION:
a 4'-
CITY: 'W1 fr4` 5 re COU 4/-
/63 C, ,
(Street Name, Numbers; Communityy, 'Subdivision, Lot No., Parcel, Bp Code)
TOPOGRAPHIC / LAND SETTI : (check appropriate. box)
❑Slope ❑Valley ❑ Flat ► ' idge ❑Other
LATITUDE 36
- e. 2144e/
Shaba Zip Code
•
•
.74° f /-iki,e4 -
ownerTme
AF,,e;ig s-de e
steetnaeresl,• 14/3"1 " ?AO yt/e,
�
• Cry or Town Slade Tip Code
?- 55‘
g. WATER ZONES (d 3:
Top 5 2 Bottom & Top Bottom
Top Bottom Top Bottork.— „ .._.....
Top Bottom Top Bottomni„_r.,—...
T. CASING: Depth Diameter
Top Bottom 05. Ftt Il
Top _ BottomFt.
TopBottom Ft.
Thickness/
$''O"p L
8. GROUT: Depth / Material , Method
Top 0 Bottom Ft. 13e 'i, rc2 r •f -e rao-,to
TopBawl—Ft.
TopBottom Ft.
9. SCR N: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top BottomFt.. in. in.
Top Bottom Ft ; n, in.
10. SAND/GRAVEL PACK:
Depth Size . Material
Top BottomR.
Top Bottom _ Ft.
Top Bottom Ft.
11. DRILLING LOG
Tod
CJ
1
11.12.11
6
" DMS OR 3X.)0000 oo X DD
LONGITUDE 75 DMS OR 7x.xxxxx0xx DD
Latitude/longitude source: [3 PS ❑topographic map
(locaffon of well must be shown on a USGS.topo map endattacherl to
this form if not using GPs)
coil
Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
H:
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 26
(Uses+s If Above Top of Casing)
•
i
12. REMARKS:
flOCT2.2 2012
NO(V. ; •
�Y :1RTIY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A t OPYOF THIS RECORD HAS BEEN
PRO ! ED TO THE WELL OWNER.
rFormation Descriptio
clix //'tf
L/5
e;
ay0,s
CErr1A. Hits
DWQiiduue
FT.
d. TOP OF CASING IS , 1 FT. Above Land Surface*
*Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 50 METHOD OF TEST
f. DISINFECTION: Type . 7 /4. Amount
•
S ' ATURE OF CERTIFIED WELL CONTRA • R D E
•
7// R/
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit within 30 days of completion to:. Division of Water Quality
17 `'Mail Service Center, .Raleigh, NC 27699 161, Phone .: [phone]
Information Processing,
Form GW--1 a
Rev. 2/09