411956_Well Construction - GW1_20130304

RESIDENTJAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2611
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 21 7 2 Ocean Hwy West
Supply NC 28462
City or Town Mate Zip Code
( 91 0- 7:&4 - b 5 2 8
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable/ 9 ! ,05 Z / t?/ AZ --
WELL USE (Check Applicable Box): Residential Water Supply10'
DATE DRILLED /*— 61-13
TIME COMPLETED 3170 AM. D PM re -
COUNTY EP-I/sae 77-
96? I 1111-: e
(Street Name, Numbect, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope D Valley 0 Flat ❑ Ridge
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source:
D Other
May be in degrees,
minutes, seconds or
in a decimal format
D GPS DTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
C)WrdNER S NAMEL5tI j3r4lIe
STREET ADDRE S 6/9 / 'Yo e 0 r.
Cot).-4, o e
City or TtYwn
State Zip Code
Area code - Phone number
5.WELLDETAILS:
: � f'j
a. TOTAL DEPTH: �1
b. DOES WELL REPLACE EXISTING WELL? YES NO D
c. WATER LEVEL Below To of Casing: `�'`�
p g FT.
(Use "i-" 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/0 f b
(gpm): METHOD OF TEST .
\,A) e)o
J
f. DISINFECTION: Type -1d
Amount
//b
g. WATER ZONES (depth):
From 5- To /t From To
From To From To
From To From To
S. CASING:
Thickness/
Depth. Di meter Weight Pt,rt
From To /4.�- Ft. S'C'Ly p
From To Ft.
From To Ft.
7. GROUT:
From
From
From
Depth 4Material Method
To & Ft. V''C)r % C , (3.5
Tog C) Ft. 15e1,1 O rL i e
To
Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From To
From To
From To
10. DRILLING LOG
From To
0- /0
/6--- 50
3o- 4/0
70— gc--
e4.--
11. REMARKS:
Ft.
Ft.
Ft.
in.
in.
in.
Material
Size Material
Formation Description
a-7vs‘sd,
,4,1,1 icy i
Ikv‘2 ,e ifti2t/
s inn 'e51,Z%N.,"\
C164 fq
FEB 2 5 7013
WATER QUALITY T ;ON
INFORMATION PROGI:L311W, d �
I DO HEREBY CERTIFY THAT THIS W
15A NCAC 2C, WEL '' ONSTRUCTIO
RECORD HAS BEE ;l; ROVIDED
L WAS CONSTRUCTED IN ACCORDANCE WITH
STANDARDS, AND THAT A COPY OF THIS
E WELL O NER.
NAI OF CERTI ` IED WELL CONTRACTOR DATE
Douglas Hewett ;�:.;����
PRINTED NAME OF PERSON CONw 6 - 1I*ELL
2°13
Submit the original to the Division of Water Qualitywithin 34 days. Attn: Information Mgt.
1617 Mail Service Center- Raleigh, Y 9. Form GWAa
Ra a gh, NC 27699- 1617 Phone No. [phone] ext 568. y Rev. 7105—