411945_Well Construction - GW1_20130304

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 61 1
1. WELL CONTRACTOR:
Douglas Hewett
Well Contractor (Individual) Name
Hewett's Well Drilling
Well Contractor Company Name
STREET ADDRESS 2172 Ocean Hwy West
Supply NC 28462
City or Town State Zip Code
( 910- 7:5&4- 528
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) /970 t) L t Z-! t 14'
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 71- %5 — l
TIME COMPLETED / - ° AMID PM •Iri
3. WELL LOCATION:
CITY: /...0 Atf (47,a0
“FD Sfrz#rre S+-
COUNTY i
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
p Slope DValley ❑ Flat ['Ridge ❑ Other
(check appropriate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source:
May be in degrees,
minutes, seconds or
in a decimal format
❑GPS ❑ 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 CY` 55 1J-4fVe'/ e 4r\Cr. 0P4-
U
STREET ADDRESS 2. 3 C. h v•e- 1°0 ("4" r 0 6) 6)
-e.
CityTh or wn State Zip Code
( )-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
sr
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
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 .011
e. YIELD (gpm):
METHOD OF TEST
4
..n-14
f. DISINFECTION: Type ( k‘ Amount
g. WATER ZONES (depth):
From 5' To 63 From To
From To From To
From To From To
6. CASING:
Depth Diameter
From C. To °I Ft. 2
From To Ft.
From To Ft.
7. GROUT: Depth
A
From 0 To 3 Ft.
From 3 To 20 Ft.
From To Ft.
Thickness/
Weight
8. SCREEN' i epth Diameter Slot Size
From �''. To 65 Ft. ,2 in. / ?
From SD To Ft. in.
From To Ft. in.
9, SAND/GRAVEL PACK:
Depth Size
From /f„,$' To Ft... -2.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 2 °-
4It
r- 6,
11. REMARKS:
Method
C ‘PS
Material
in. Pv
in.
in.
Material
Formation Description
C C
/Ay
e_
6c- A; s~ Cf
rt13 2 5 2013
WATER OUA .i rY SECTION
INFoRMATI0N PPOCESSING
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CON ' UCT1ON ST DARDS, AND THAT A COPY OF THIS
RECO: • BEEN PR �j ► ED TO mg WELL OWNER.
ELL CONTRACTOR DATE
Douglas Hewett ;w
PRINTED NAME OF PERSON CONSTRUCTI I G ;HE LLB
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.
MARF.T ipv2943
Rev. 7/05
sa
RV