411952_Well Construction - GW1_20130304

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2611
9. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
Supply NC
City or Town f5tate
( 91 0- 7-4 - 528
Area code- Phone number
•
28462
Zip Code
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) GAO/2/ / 7 ,
WELL USE (Check Applicable Box): Residential Water Supplytr'.
DATE DRILLED 5-/-3/-/a-
TIME COMPLETED '3 t)0 AM.❑ PM f
3. WELL LOCATION:
CITY: kO�1 1.1/,:'0 COUNTY faiiii/St-"
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑ GPS D Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER OWNER'S NAME �'�.,.�'
�, ©/' t. �,.� v``
��/
.
Rd.
STREET ADDRESS 0 �C'cd , «w
. tee. ,a4ie24)
May be in degrees,
minutes, seconds or
in a decimal format
City or Town State Zip Code
( )-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO fr
c. WATER LEVEL Below Top of Casing: / FT.
(Use "+" 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 (gpm): METHOD OF TEST /,J,./ /
4 1
f. DISINFECTION: Typeit 1. Amount lib
t 2
g. WATER ZONES (depth):
From 30 To .3 O From To
From To From To
From To From To
6. CASING: Thickness/
Dept/ Diameter Weight PP?
From To - Ft. t� ` el. 0
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
(-2
From I To . Ft. 6e/X.h t OA i -S
From 1 TaJ 0 Ft. A...4
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
_96 ,g
,()
11. REMARKS:
5ppti sty
C 7
• g
5 IL el' /IT C_
FEB 2
WATER QUAL i .j.,.::� T i�
INFORMA' +Oh PR )C S NG UNIT
l 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 BPROVIDED TO THE WELL OWNER. .
ATJR OF CERTIFI WELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRRli
,-.rear:
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.
AR 0 °PM
Rev. 7/OS