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HomeMy WebLinkAbout385895_Well Construction - GW1_20100101RESIDENTIAL WELL CONSTRUCTION RECORD North Caroima Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # 1 WELL C9NTRACTOR: Y �t /2/4?_ i C e Latitude/longitude source (location of well must be sho this form if not using GPS) 5 WELL OWNER/) j- i ., City or Town (s4) 73-824- Area code Phone number S WELL DETAILS• a TOTAL DEPTH.��y Well Contractor (Individual) Name /Lfr � �G f'Se125 I $Cx WeII Contractor Company NSme Bias" e Street Address /fit 19"t% ,c7,.i �L Crty or T drwn d State Area code Phone number 2 WELL INFORMATION: wag Zip Code r. WELL CONSTRUCTION PERMIT# 7 e�'! - Cry 6; OTHER ASSOCIATED PERMIT#(r; applicable) SITE WELL ID #(rf applicable) 3 WELL USE (Check Applicable Box) Residential Water Supply DATE DRILLED TIME COMPLETED a WELL LOCATION: CITY (eEj _3 1 AM O PM COUNTYUe_ r' Le (Street Name Numbers, Community, Subdivision Lot No , Parcel Zip Cod6)/ TOPOGRAPHIC / LAND SETTING (check appropnate box) ❑Slope AValley oFlat t]Ridge ❑Other LATITUDE 36 `3•S • �' Y•• DMS OR 3X XXXXXXXXX DD LONGITUDE 75 " - • 1 3 o^DMS OR 7X xxxxxxxxx DD PS ['Topographic map on a USGS topo map andattached to b DOES WELL REPLACE EXIS"nNG WELL? YES ❑ NO c WATER LEVEL Below Top of Casing r.r 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 vanance in accordance with 15A NCAC 2C 0118 e YIELD (gpm) METHOD OF TEST • G f DISINFECTION: Type Amount Submit within 30 days of completion to: Division of Water Quality - 1617 Ma it Service Center, Raleigh NC 27689-161, Phone . (919) 807-6300 State Zip Code g. WATER ZONES (depth) Top Bottom q, Top Bottom Top Bottom Top Bottom Top Bottom Top Bottom 7 CASING Depth Diameter 6 Top 0 Bottom " Ft fit' Top Bottom Ft Top Bottom Ft Thickness/ Weight ateriai 8 GROUT Depth Matenal Top 0 Bottom Q Ft e_e e,) t Top Bottom Ft Top Bottom Ft Method 9 SCREEN• Depth Diameter Slot Size Material Top Bottom Ft in rn Top Bottom Ft in in Top Bottom Ft in in 10 SAND/GRAVEL PACK Depth Size Material Top Bottom Ft Top Bottom Ft Top Bottom Ft 11 DRILLING LOG Top Bottom C / 6G / / 12 REMARKS Formation Descnption CPUe2 a R E C: E 1jj .IUI 2 7 2n10 Information Processtnc�Untt DWQBOG I 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 BEEN PROVIDED TO THE WELL OWNER letrak.'ts• SIGNATURE OF CE PR IFIE WELL TED NAME OF PERSON C IONTRACTOR NSTRUCTIN information Processing, DATE JAN' 1 1 2O1 m GW-1a Rev 2/09