411440_Well Construction - GW1_20130211

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION # /51
1. WELL CONTRACTOR:
Contractor Company N e
Well Co tra or In victual) NameHC e f lale piti Cu
Contractor Company N e
Well �rZ //4
/04/1/V4fr
��/i� �i
;4(Y7'
STREET ADDR S$/ �� j
City or own ate Zip Code
( � y
Area code - Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable)
STATE WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Ap icablBox): Residential Water Supply 0
DATE DRILLED
f44P,)
TIME COMPLETED AM 0 PMeJa
CITY ed •�� ��Q , COLIN'1�Yv` ��"
3. WELL L CAT i
3. WELL LOCAT i N
.` AK
(Street Name, Numbers, Community, Supervisor, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope ❑ Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER Air
OWNER'S NAME e q t- a ,
STREET DD S S d` ,1 ate- `G
0,
alA474ael// AGe- ry7z.
(
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: C, <5 4
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO ❑
c. WATER LEVEL Below Top of Casing cc° FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS /5" 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) Y 0 METHOD OF TEST 05,11.11.
411440
4 0
f. DISINFECTION: Type
%414 "Amount
g. WATER ZONES (depth)
From To From To
From To From To
From To From To
6. CASING: Thickness/
Dep D'
a eterga Ma ' al
From 40 Tor # Ft. JetI
G V
From To Ft.
From To Ft.
7. GROUT: Depth / Material
From 0 To `e Ft.
40
From_ To/ Ft.
From To Ft.
Method
8. SCRE Deptlav ,.0 Dia eter Slrize ateal
Fro
To Ft. in.in O
From To Ft. in. in.
From To Ft. in in.
9. SAND/GRAVEL PACK:
De th Mfki'al
4� h�
m � To� Ft.
Fro
From To Ft.
From To Ft
10.- DRILLING LOG
m er)74;aation Description
Y
34/ 47/
4 7t. cil4y
// /v
/ 7 e
S46011
11. REMARKS:
RECEVED.
FEB
information Processing
DWQ/BOG
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 EE1*PROVIDED TO THE ' QWNER.
SIGN URE OF CERTIFIED WELL COTR,rR
S13
PRINTED NAME OF PERSON CONSTR[ C'IN& ` ' WELL
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.
�?> r
W
Form GW- l a
Rev. 7-05