411953_Well Construction - GW1_20130304

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 61 1
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 21 72 Ocean Hwy West
Snppl y NC 28462
City or Town State Zip Code
( 91 0-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
applicable) MY-��`'- o o 9b
DWQ or OTHER PERMIT #(if a ppl }
WELL USE (Check Applicable Box): Residential Water Supply Erei
DATE DRILLED g—c,—
TIME COMPLETED AM. D PM
3. WELL LOCATION:�1,
vV CITY: 4 E? c.
COUNTY OfAA.5
9.2- As 41, kd
(Street Name, Numbers, Comn pity, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope DValley D Flat ❑ Ridge. D Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: D GPS DTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
May be in degrees,
minutes, seconds or
in a decimal format
4. WELL OWNER r.
OWNER'S NAME i 4f ¢ e-s Ct.) 0 c k
STREET ADDRESS '9 . f'&(/C /J)r- 1
Nil u/ v t
City or Town State Zip Code
( )-
Area code - Phone number
5. WELL DETAILS: / C
a. TOTAL DEPTH: 1 �,Jr
7crio r
b. DOES WELL REPLACE EXISTING WELL? YES D NO
c. WATER LEVEL Below Top Casing: Casin :17 FT.
(Use "+" if Above Top of Casing)
d. 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 .0118.
e. YIELD Wpm): / 3 METHOD OF TEST ti,
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From /33 To / From To
From To From To
From To From To
6. CASING:
Thickness/
From C.JTo Ft. Diameter 5 141C1
From To Ft.
From _ To Ft.
7. GROUT: Depth
From 0 To 3 Ft.
From 1 To Ft.
To Ft.
From
Material
ge hock
8. SCREEN: Depth Jr; Diame er Slot Size
From — To / , Ft. Z. in.
From To Ft. in.
From To Ft. in.
in.
in.
in.
Method
c .0
Mrt
9. SAND/GRAVEL PACK:
Depth Size Material
From To FL
From To Ft.
From To Ft.
10. DRILLING LOG
From To
/a: 4f-0
11. REMARKS:
Formation Description
Foie
0 /Ai
5)4,1
z
FEB 2 6
ATh
INFORMATION OCLS ( UNIT
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTE0 TANDARDS, AND THAT A COPY OF THIS
R CORD HAS BEE -.' OVIDED TO ' E WELL 0 .:i R.
OF CERTIFI D WELL CONTRACTOR
DATE
Douglas Hewett
PRINTED NAME OF PERSON 1 CONSTRUQyTG t WE -. r
; �',.�.,.... � � @;�h fir,,
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
L
MAR Ootip
Rev. 7/05
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