411949_Well Construction - GW1_20130304

NON 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
( 910 )- 754-6cj28
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring D Municipal/Public D
Industrial/Com rcial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation` Other 0 (list use)
DATE DRILLED ~ 21- -
TIME COMPLETED
3. WELL LOC TION: ,
CITY:
AM p PM Lys
COUNTY
? 4.1 /14-ecJrally041-
(Street N me, Numbers, Cot munity, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
D Slope D Valley D FIat D Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: DGPS DTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY- is the name of the business where the well is located."
FACILITY ID #(if applicable)
NAME OF FACILITY to dX4)bAo 54,
STREET -ADDRESS j k 9Vy
`tom. '-
City or Town
CONTACT PERSON e
MAI ING, ADD S
State
144
41/4
City or Town State
Zip Code
Yid > s z3- Ys..e
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
3-
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOW"-,
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
FT.
. /111949
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): 2N� METHOD OF TEST A. "
f. DISINFECTION: Type '14 [--- Amount
g. WATER ZONES (depth):
From 3D Tom;? From To
From To From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight M oe,From To Ft: SZ.4�
From To Ft.
From To Ft.
7. GROUT: Depth Material
FrorD Tooi� Ft.
441:4
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter
From3f— Ta5D Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Method
Vim
Slot Size Material
as
in.
in.
in.
Pec
Depth Size Aaterial
From Toy Ft.. / 4
From To Ft.
From To Ft.—FEB 2 5 7013
10. DRILLING LOG
From To
t5-
5-- c2
30•- SO
11. REMARKS:
VgirtgeTION
1415Mr0:39ING UNIT
ei14_1
*co.('
c,
-s 1e\k C S ot. C�
I DO HEREBY CERTIFY THAT THIS WELL
1 AC 2C, WELL C TRUCT1ON S ANDARDS ;,;. D THAT A COPY OF THIS
S BEEN P' . ►ED TO
SIG
AS CONSTRUCTED IN ACCORDANCE WITH
C RTIFIED ELL CONTRACTOR DATE
Douglas Hewett
PRINTED NAME OF PERSON CONSITRLIF fijld :FlitEAN
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.
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