411947_Well Construction - GW1_20130304

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 6 1 1
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
Supply NC 28462
City or Town (State Zip Code
( 910- 7.5:4 .6528
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) j VCP - /?Oo2/O
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED .Y-7 /c2.
TIME COMPLETED . 1' 1'
3. WELL LOCATION:
AMO PM�
�%�.. COUNTY Co/omCITY. /V4/b �
/ ci-D C&S• r,
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope D Valley . D Flat D Ridge
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: D GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNERS NAME ,4r d /94"t111()Yt
STREET ADDRESS /14 7OC 0 r`
D Other
May be in degrees,
minutes, seconds or
in a decimal format
/141r.‘,1
City or Town State Zip Code
( )-
Area code - Phone number
5. WELL DETAILS: ig
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES NO D
c. WATER LEVEL Below Top of Casing: 3 42 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 (gpm): /I) METHOD OF TEST t.14I
/0
I I 4 7
f. DISINFECTION: Type Amount __Y22/2_
g. WATER ZONES (depth):
From To IS From To
From To From To
From To From To
S. CASING: Thickness/
Depth j1 D. meter Weight Mat rial
From 0 To /0,5 Ft. e A 4 r/
From To Ft.
From
To Ft.
7. GROUT: Depth Material
From 0 To 3 Ft. &,/€i e.
From 3 To 3 a Ft. /3 e i?,a i
From To Ft.
8. SCREEN' Depth Diameter Slot Size
Method
PJny°
MAterial
From ArS—To /80 Ft. a in. %ca- in. i"
From To FL in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From, To
1710-- /TIT—
>D v —I 96— 1)
1� d
/02 b 4
ILO"-
11. REMARKS:
Formation Description
141-/ /
CV/ / it-be-4
RI)C1-f c- I it; rte.. 4.�
5 Aiii‘d_
S I¢n�
WATER rAJALIT1 SECTION
FORWMN PROCESSING W
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
I Ee9RD HAS BEET*PROVIDED TO ThrE WELL OWt
l l
SIGNAT E OF RTI ED W- EL- L CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUCT �NG"TI- E 1 ELL
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.
AR OFfir
Rev. 7/05
nzzti: