404833_Well Construction - GW1_20120501

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # (41q
iy)
i-ActiI.
MPS� WELL CONT CTOR••
W II Contractor (Individual);Name 4...four/ sec v xeS
Well nt ctor Company Nam
Hwye
jr7
Street Address-e4d
N C_
City or Town State
(C{1O ) aS l- Caq
Area code Phone number
8C-1643
Zip Code
2. WELL INFORMATION: W PO aCtO6Q
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable) 1l le a 3/97
SITE WELL ID #(if applicable)
3, WELL USE (Check Applic
DATE DRILLED
TIME COMPLETED
•
•
•
•
4. WELL LOCATION: ;: •
•
CITY: ‘VPIA ncjeCOUNTY Nolo ove1►
esidential Water Supply 0
AM 0
1776 A dot cd8c1 1
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
( qlo r) �S6CIT56.
Area code Phone number
6. WELL DETAILS: 1/46
a. TOTAL DEPTH: —
b. DOES WELL REPLACE EXISTING WELL? YES NO ❑
FT.
PM
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley D Flat ❑ Ridge ❑ 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 O�
ow�e,Name (YI4QC4)
hn78' A-locinkr R�
st,Q,�dress
1 r_lint400 NC ai��f I �
t
State Zip Code
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface's
*Top of casing terminated at/or below land surface may require
a variance in a or nce with 15A NCAC 2C .01 8.
e. YIELD (gpm): METHOD OF TEST lt it
t
f. DISINFECTION: TypeCh LOX ' Amount O; LbSt�
Top
Top
g. • T R ZONES (d
Top AI Bottom �� Top Bottom
Top IL,Bottom i` Top Bottom
Top Bottom Top Bottom
C E 847 0
7. CASING: Depth Diameter
4 if"i
Top Bottom di" Ft.
Top— Bottom y Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom ~ Ft.
Top "3 Bottom __;a Ft.
Top Bottom Ft.
Thickness/
I . hMaterial
9. SCREEN: Depth Di eter Slot Size Material
Top WAS Bottom Ft. 04 in. 400 in. PvC..
Top 60 Bottom (It Ft. in. g4Ce in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Si ;� _ Ma6srial
To • Bottom 1 Ft.
Ft.
Ft.
Bottom
Bottom
11. DRILLING LOG
Top Bottom
1
to
12. REMARKS: •,,_74P *fit -4/0-
vs %La
SI II 11Nral EMI re LW
-� . .41 dries
1 DO HERE:Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
: ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
• PROVADD TO T _ WEL T ' ER.
F r ation e .c • Lion
_`
elg3vffcyoe
�9AY k 41112
Submit within 30 days of completion to: Division of Water Quality
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :`:(919) 807-630
TE
CERTIFIED WELL CONTRACTOR DATE
e.--
AME OF PERSOr1'CON$YRUCTWG THE WELL
Form GW-la
Rev. 2/09