403333_Well Construction - GW1_20120305

ESIDENTIAL WELL CONSTRUCTION RECORD
Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTR CTOF :
i _e.__
ell Contractor Individ ral) Name
1; a t. Of 1 1 \ : n .-- ?imp -
ell Contracto-Comp y Name
a\a
l i j y i 7
Street.Address -
t~:it or Tow466.61
Area r;ode Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#_
State Zip Code9
Q0NO s()Q
OTHER ASSOCIATED PERMIT##(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check plicable Box Residential Water Supply r�
DATE DRILLED
TIME COMPLETED
4. WELL LOG TION:
CITY:(...k.)1
)(Street Name, N tubers,
AM ❑ PM
COUNTY
ommunity, Subdivision, Lot No.,ei, Zip Code)
TOPOGRAPHIC / LAN ETTING:
D Slope 0 Valley lat C[idg
LATITUDE 36 °
LONGITUDE 75
Latitude/longitude source: D3PS
(location of well must he shown on a
this form if not using GPS)
5. WELL OWNER
(check appropriate box)
E Other
" DMS OR 3x.xxxxxxxxx DD
" DMS OR 7X.XXXXXxXXX DD
❑Topographic map
USGS typo map andattached to
VC, ;€.q.43
Cliff or Town ,66A
State Zip Code
Area code Phone number
(N-cil
5, WELL DETAILS, las
a, TOTAL DEPTH: 11
b, DOES WELL REPLACE EXISTING WELL? YES II NO n
IIc. WATER LEVEL Below Top of Casing:"' 3
(Use "+" if Above T of Casing)
ct. TOP OF CASING IS_ FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0i18.
e. YIELD (gpm): 010 ETHO[) OF TEST
f, DISINFECTION: Type Amount
FT.
•
•
•
•
•
•
•
•
A-4
g. A " TER ZONES d •
Top II Bottom i Top Bottom
kuy)____ Bottom EL Top Bottom
Top Bottom Top Bottom
vkOAD
•
4633,: ,
7. CASING: Depth
Top4
Top
Top
Bottom
Bottom'`
Bottom
8. GROUT: Depth
Tops-5 Bottom
Topa_ Bottom"' Ft.
Top Bottom
Thickness/
Diameter Weight
Ft. 4 ��?stito
5.7.40
Ft.
Ft.
aterial
Method
9. SCREE • Depth ci Diameter Slot Size
Top r Bottom- Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom _ Ft. A, / i Top Bottom Ft AI� "/�/►
;i
Top Bottom
in.
11. DRILLING LOG
12. REMARKS:
Ft.
Size
atoll
Material
or atio De rip ion
FEB27�12it _
WATER QUALITY Y SECTION
?ON
IN + ,Jrj_PC.S.iti 4UNIT
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
PROVID •J/a THE. ELL OM
°-\I-Fa•
SIG ATU' O3' ' IED ,WELL CONTRACTOR DATE
1.
, e.
PRINTED NAME F PERSON CO'TR ING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone] r
qiq o7/i'
Form GW-1 a
Rev. 2/09
6(1#- 711 —7691