385895_Well Construction - GW1_20100101

RESIDENTIAL 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 . [phone]
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