386820_Well Construction - GW1_20100101

RESIDENTJAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2Ss 1p
1. LL CONTRACTOR.
1►ri.� ' 6(bb�+-
ell Contractor (Individual) Name
Swtt.4Wa44- W-69
Well Contractor Company Name
Street Address
C")*i ar\rl CAr O Q
City or Town
(P52_413) 7eIr�3-((tom
Area code Phone number
2 WELL INFORMATION
State Zip Code
WELL CONSTRUCTION PERMIT# \A.t EL 201 O.
- b00-1 Q
OTHER ASSOCIATED PERMIT#(it applicable) to/
SITE WELL ID #(if applicable) ti/ k
3. WELL USE (Check Applicable Box) Residential Water Supply (
DATE DRILLED 8- IZ- I O
TIME COMPLETED
1
AM ❑ PM;S1
4 WELL LOCATION /
CITY 'avrx t-e COUNTY J ,
1PDSib \-cs 201
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley 'EgFlat ❑RRiidge ❑Other
LATITUDE 2s ° 29' a 92 " DMS OR 3x XXXXXXXXX DD
LONGITUDE' ceZ ZZ. Stp-1 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source
(location of well must be sl
this form if not using GPS)
PS [Topographic map
wn on a USGS topo map andattached to
5 WELL OWNER
---\c>V1Ck'- -1-
Owner Name
IStreet Address
tie
City or Town
2(1--.39/(3
Area code Phone number
6. WELL DETAILS
a TOTAL DEPTH JL�Sr
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO t�
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
d TOP OF CASING IS Above Land Surface*
*Top of casing terminate at/or below land surface may require
a vanance in accordance with 15A NCAC 2C-I 0118^M
e. YIELD (gpm) METHOD OF TEST t 11Qd
LOTS FT
f DISINFECTION Type S._C/i-k Amount /007.
3 w C 8 2
g WATER ZONES (depth)
Top Bottom Top - Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING
. Depth Diameter Weight A/C -
Top Top" L / Bottom 165 Ft c CrnT/ C-
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal7
Tore.).Bottom Ft enk ri t-
Top Bottom Ft G(\ I
Top Bottom Ft
9 SCREEN- Depth Diamete
Top Bottom in
Top Bottom Ft ► in
Top Bottom
10 SAND/GRAVEL PACK
Depth
Top Bottom
Top Bottom
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/
/ RECEIVED
SEP 0 2 2010
ze
Sc
Method
n
Slot Size
in
in
In
Material
Material
Formation Descnption
i
12 REMARKS
Information Pruceysl
DWO/gp{� ng Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRTJCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVED TO THE WELL OWNm
8
SIGNAT OF CERTIFIED WELL CONTRACTOR DATE
t/1� £ di,?
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Q Submity►lthim30-days of completion to:' Division of WaterQualitit `Jnfonnation Processing;
1617 Maii,Service Cehter,,Raleigh; NC 27699-161, Phone [phone]QO ..t ti r - - -;1_�
Q Form GW-la
JAM 0 7 2d3" 2rog