388898_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2150 -A
1 WELL CONTRACTOR
Gary Justice
Welt Contractor (tndmdual) Name
Justice well dnllina
Well Contractor Company Name
3845 us 70 west
Street Address
marion no 28752
City or Town State Zip Code
( 828 ) 724-4548
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# .) b / 0 - 0 0 (/ S /
OTHER ASSOCIATED PERMIT#(if applicable)1 i31C - to 45 /
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED / o/t 5/ PO
TIME COMPLETED AM 0 PM ❑
4 WELL LOCATION
CITY Eitika.
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
Slope DValley ❑Flat DRidge DOther
LATITUDE & `r35" ' �' " DMS OR DD
LONGITUDE �bZ °42 ' 5A "DMS OR DD
Latitude/longitude source BPS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
nn COUNTY diallAtelitile
lU�
5 WELL OWNER
TOFtCAA' 144 LN/1►►�
Owner Name
1343 RA L- / t2-c co ti-g -12
Street Address
e' Ott. -e4A_ 1t.)
City or Town State
(gZ8 ) (vg 7 - /o/'
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH. , j ©6
p de
b DOES WELL REPLACE EXISTING WELL? YES D NO fa/
c WATER LEVEL Below Top of Casing 5® FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 7Y FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118 �l
e YIELD (gpm) aMETHOD OF TEST 'Peril
f DISINFECTION: Type C LPIZi AK Amount I (D b2
g WATER ZONES (depth)
Top t Bottom e74e) Y2��/Top 7/d Bottom
Top r D ' � Bottom 44 2/ITop 4 9O Bottom 4040 /
Top 3(DO Bottom 380/'&op Bottom
Thickness)
7 CASING Depth Diameter Weight Matenal
Top 0 Bottom /O 8 Ft S 9/Z Z/ PUC
Top Gig Bottom 7(7 Ft i o 19 .i gg .5-64
Top Bottom Ft
8 GROUT Depth
Top Bottom
Top (/' Bottom
Top Bottom
yQ
Ft
Ft Ft 3J2JJ2,
Matenal
0
388898
"'Z
Method
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Too Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/D Z / 4 Zo
/
Sae
Material
Formation Descnption
s g
411t( g b )
12 REMARKS
2 0 2Or
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
PR.:DEDTOTHE WELL O
WE
I_L CONTRACTOR
Gary D JusticeE
-' E(~1-:1`/-
PRINTED NAME OF PERS ON CONSTRUCTING4 THE WELL
010
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
Information Processing Unit
DWQ/BOG
1617 Mail Service Center, Raleigh, NC 27699-161, Phone • [phone]
Form GW-1a
Rev 2/09