412572_Well Construction - GW1_20130408

OTHER ASSOCIATED PERMIT#(ilapp cable)
SITE WELL ID Nil applicable)
1i! ESIDENTPAL WELL CONSTRUCTION RECORD
North Carolina Department or Environment and Natural Resou ces- Division of Water Quality
WELL CONTRACTOR CERTIFIC.ATiON #
1. WELi t-ir ;a Sage_
W Con raclor (In ' idual) Name
e ici1i it'rBe +Pu,rnpseau°/�
,Jy6ll t glractOr Compa Tme /// P n� /t
ddress
f('��Str- eetA1krnlnQTC�n i\ C a@gii
(c.iOCity rI Town a3►-661� Stale Zip Code
Area code Phone number
2. WELL. INFORMATION: V` , L-�q
WELL CONSTRUCTION PERMIT# / ^ C� H
©T . 36
3. WELL USE (Check Applicable Box): Residential Water Supply El
DATE DRILLED 3 — ! 1-
TIME COMPLETED '. AM PM
:WELL LOCATION: QS //U6OU;g, `g C
MaCC; ! Ln, LS- SG zggS
(Street Name, Numbers, Community, Subdivision, Lot No., P rcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope Malley 0 Flat 0 Ridge ❑Other
LATITUDE 36
LONGITUDE 75
"DMS OR 3X.XXXXXXXXX DO
" DMS OR 7X.XXXXXXXXX OD
Latitude/iongilude source: 17GPS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OW Iu CSYY 0 Rd%IM.e s
Owner Nk O n _ fl <y L'T(1rnLrn�Jt Lljj�lrnit^ faint (dJUrI/
Strpel A©ces. s , 1r ?gin'J A/` p� 1. )
City or Town ly State Zip Code
(LynaSI-.�,(,(�9,
Area code Phone number
6. WELL DETAILS: 1��
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 400 2Gr.
(Use "+" if Above To of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gem):', )IC) METHOD OF TEST
f. DISINFECTION: Type Amount
nil
g. TER ZONES (depth :
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth �t Diameter Weight Material
Top 4J. Bottom - (CC Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top b Bottom_
Top Bottom Ft.
Top Bottom Ft.
Material Method
Ft. 1( felred5
9. SCREEN: Depth Diameter Slot Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom - Ft.
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
in. in.
in. in.
in. in.
Size Material
Material
11. DRILLING LOG
B
12. REMARKS:
For .lion . ciliation
MAR 2 Fr, 2013
INru. 'dIA UU�e
I DO HEREBY CERTIFYTHAT THIS WELL WAS CONSTRU D IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECO D HAS BEEN
PROVIDED TOT W LOWNER.
PRINTED NAME OF PERSS014 CONSTRUCT!
Submit within 30 days of completion to. Division of Water Quality = Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09