411088_Well Construction - GW1_20130204

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II Contractor Indivjduai) Name
c 111; nc\ �r fc t.cv e SefceS
.1S'I`C nfracc IcLna7 V in Rai
Street Address 7 ^�g
W I Q(lty,,1
( Ciy )) Si Zip CCo e
e ti 311
Area code Phone number
2. WELL INFORMATION: �
WELL CONSTRUCTION PERMIT# � Va-0 ' 7 j
OTHER ASSOCIATED PERMIT#i(if applicable)
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ic�ablee).)�...yy
SITE WELL ID #(if applicable) L e T .
3. WELL USE (Check A[p licabl ox): „$\esidential Water Supply ❑
DATE DRILLED 1 , \ds
TIME COMPLETED 7.34,:n6 AM 0 PM Lr'
4. WELL CF
CI Y:St- yj. CA -* COUNTY B e. el
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Res(ouurrces-Di vi5jon> f at�r Quality
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WELL CONTRACTOR CERTIFICATION #
411088
g. W ER ZONES (de t
Top ._ Bottom R' I ..,S Top Bottom
Top Boitom Top Bottom
Top Bottom Top Bottom
// Thickness/
CASING:7. Depth QQd�, Diameter
Top4 Bottom `Cr) Ft.L.hiCh 40 V
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top Bottom
Top Bottom
Top Bottom Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
�/1 Lane,
/ ¢� Top Bottom
+l A I LA e, Le- 0tJ Ib Top Bottom
Street Name, Numbers, Community,Sub�kimision, Lot No., Parcel, Zip ode) Top
TOPOGRAPHIC / LAND ^ TfING: (check appropriate box)
OSlope OValley at ❑Ridge ❑Other
LATITUDE 36
" DMS OR 3x.xxxxxxxxx DD
LONGITUDE 75 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: D3PS Dropographic map
(location of woll must bo shown on a USGS topo map andattached to
this form if not using GPS) i C
Silt OWN R •
loafs Inc
er Na e J f o
cix
tr A rr ss nat
( Cit or)T wnD ri -q ry State Zip Code
Area code Phone number
6. WELL DETAILS. t5'- -}-
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? Y S D NO IY
c. WATER LEVEL Below Top of Casing: -f I L FT.
(Use "+" if Abovve,Ttop of Casing)
d. TOP OF CASING IS 7 .L FT. Above Land Surface*
"Top of casing lerm'nated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. [�
e. YIELD (gpm): METHOD OF TESTA; V )y rt. :t
f. DISINFECTION: Type II 0e- Amount & 1105
in.
in.
in.
Size
Ft.
Ft.
Bottom Ft.
11. DRILLING LOG
12. REMARKS:
in.
in.
in.
Material
to B
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WEL -INSTRUCTION
STANDARDS, AND THAT A COPY OF - S RECORD HAS BEEN
PROV0 TJzfE`LL OWN
1 —13
SICNAT+ �• CER �D WELL ONCTOR DATE
PRINTED NAME OF PERSON CONSTRUC ING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
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Information Pro essing;_.
JAN282013
F.;! Form GW-1a
Rev. 2/09