411436_Well Construction - GW1_20130214

4-C7Y
ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRAC
Well ✓, n . ctor ( vid .:)Name
b1411//4/4
Well Contractor Co pany Name
STREE DR S
),4'7
A4Wi oee./i0--/
City or own State Zip Code
`o _ L 2W,1,5
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 Applic ble B x): Residential Water Supply ❑
DATE DRILLED. `tri.)
TIME COMPLETED 54 � ' AM ❑ PM 0,--
3. WELL LOCAT
CITY
courrukii
ge4/t
(Street Name, Numbers, Community, Supervisor, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
(location of well nzust be shown on a USGS topo map and
attached to this fonn if not using GPS)
4. WELL OWNER
OWNER'S NAM
o,'esz
STREET�P,DDtESS /g'y
//6- Ate -
/7z-
City or Town State
( )-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOE
S WELL REPLACE EXISTING WELL? YESffr. NO ❑
Zip Code
60.
c. WATER LEVEL Below Top of Casing FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 04 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)
METHOD OF TEST
f. DISINFECTION: Type 1
g. WATER ZONES (depth)
From To From
From To From
From To From
6. CASING:
De D' eter
6P Q/
From '14 0 Ft.
From To Ft.
From To Ft.
tloti
l4/ Amount 7,'Lj
To
To
To
Thickness/
W8eit e/ b Ma '
7. GROUT: Depth Material
From e To ' Ft.
From To/€,9 Ft. 801,--/bik',e
From To Ft.
8. SCRIM Dep
Fro
From To
From To
9. SAND/GRAVEL PACK:
Fro
"I� �b
From To
Dieter Sl�Size
Ft. in. 0 in.
Ft. in. in
Ft. in in.
From To
10. DRILLING LOG
From To
3s �a
LA0 5G
o
3L / 44Z
lvZ
6 ? /Jo
/ o /�z
�z /sG
11. REMARKS: •
Fr
Ft.
Ft
Material
tion Description
eerAkee 7"'b
6Pc4->e-
eiV4*>/-
5Q4P
FyJi`'-~s f
a 0 1 Zfl
p�r
I DO HEREBY CERTIFY THAT THIS WELL WA
15A NCAC 2C„ WELL CONSTRUCTION STANDARDS, AND
RECORD II4 EEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTI
D IN ACCORDANCE WITH
HAT A COPY OF THIS
fr6*I erie—
WELL CONTRACTOR DATE
INTED NAME OF PERS
CONSTRUCTING THE WELL
-4).763
Submit the original to the Division of Water Quality within 30 days. Attn: Information Ygt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone I _ .[phone] ex _568.
Form GW-1 a
Rev. 7-05