411946_Well Construction - GW1_20130304

•
RESIDENTIAL WELL CONSTRUCTION RECORD'
North Carolina Department of Environment and Natural Resources- Division of Wate 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 Nf 28462
Zip Code
City or Town f5tate
( 910- 7:54- :828
Area code- Phone number •
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable) C�
DWQ or OTHER PERMIT #(if applicable) / r q2%I41rD ?»-L/
WELL USE (Check Applicable Box): Residential Water Supply ir
DATE DRILLED 171— 41/
TIME COMPLETED Lib .1 L) AM ❑ PM EV'
3. WELL LOCATION:
CITY: 64-0)1P4'00" COUNTY RrV%lsv-' e' 4
22?s Fire 54-Viv Or.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope ['Valley 0 0 Ridge ❑ 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
j
OWNER'S NAME I t tTl ` %
May be in degrees,
minutes, seconds or
in a decimal format
STREET ApDRESS erg% 0 / Oe-
P-141) 1131gin
City or Town State Zip Code
( 10 )-
Area code - Phone number
5. WELL DETAILS: 413a. TOTALDEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES k#40 ❑
c. WATER LEVEL Below Top of Casing: /0 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 /O. v
f. DISINFECTION: Type 7 ij Amount
g. WATER ZONES (depth):
From 0 To 4I3 From To
To To
To To
Yi a
From
From
From
From
6. CASING:
Depth...)Di eter
From To ft.1 Ft.
From To Ft.
From To Ft.
Thickness/
Weight Ntteri�l
SC- � �
7. GROUT: Depth Material i
From 0 To D Ft. aeilCvl e
From To Ft.
From To Ft.
Method
8. SCREEN. ^eptl- Diameter Slot Size From To Ft. in. % ID in. Prt
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
DepthSi e
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
(90 O
o
11. REMARKS:
M rein/
•-' /' v-e
Formation Description
�j p°+ 1~ L
p4L7
k-.k 1.20e t-t
FEB 2 i2fl13
WATFF/ nUAI !TY SFC T ION
INFORMATION PROCIESSINP UHT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU TED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTIO TANDARDS, A THATA COPY OF THIS
D HAS BEEN P VIDED TO WELL OWNE
SIG 1 RF CERTIFIED WELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSTRUI5TNG' TE'"'wEL
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
C n
'or -lak,
Rev. 7/05 '?