380382_Well Construction - GW1_20100615

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # .3 / 0V•['
1 WELL CONTRACTOR hi'
/
4-J1 fr. hi'ry ES
I Contractor Indivlduaq Name
/t � OAi LLJEII 62/Yc`Zmp Li-C.
Well ontractor Company Name �L
STREET ADDRESS r173J � 10 LE!CESJEE //GUy
Z-ittS J,Et'C� LC
City or Town / State Zip Code
(>5� gL9le_
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) W1..5 - D //3i
STATE WELL PERMIT#(itappticable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED /2 1/ `
TIME COMPLETED 3 CV AM ❑ PM Er-
3 WELL LOCATION/�
CITY ['•CPJ% COUNTY %�r+Ga-4C
�n Y un t 49i
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑ Valley ❑ Flat Cidge ❑ Other
(check appropriate box)
LATITUDE 3 r ;34 6 72
LONGITUDE r Z i%/. Z47
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source tPS oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GP
4 WELL OWNER
OWNER'S NAME
STREET ADDRESS
om e5
CC382
eteicn-Ailiet%
OS
,sheu,'t!le.. Arc -- n)Q (e
Zip Code
City or Town
State
a501- 49691
Area code - Phone number
5 WELL DETAILS
a
b
c
d
TOTAL DEPTH 3
DOES WELL REPLACE EXISTING WELL? YES 0 NO /
WATER LEVEL Below Top of Casing FT
(Use -+' if Above Top of Casing)
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) 20 METHOD OF TESTZ)1 Wt d5
f DISINFECTION Type L''u"-^t
g WATER ZONES (depth)
From GV() To
From 17C) To
From To
6 CASING
Amount fT °
From To
From To
From To
Thickness/
Depth piameter Weight
From 0 To S/ Ft /?J- 1€'1/
From To Ft
From To Ft
Material
7 GROUT Depth Material Method
/�
From iv To so Ft COACT t .
From To Ft
From To Ft
8 SCREEN Depth Diameter
From To Ft
From To Ft
From To Ft
9 SAND/GRAVEL PACK
Depth
From
From
From
Slot Size Material
In in
In In
in in
To Ft
To Ft
To Ft
10 DRILLING LOG
From To
0- Yb
Yt S/
.lvs' ,
11. REMARKS:
Size Material
Formation Description
C'A^r
sir%/
G "ant F
r_...4 le,
4 Hl
'
111.1 1 ' ZUlil
i, lformat,on Processing Unit
DV1'`(.yDOG
1 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
SIGNATURE OF CrERTIFIED WELL CONTRACTOR DATE
P/A A'N
iv es
RINTED NAME OF PERSON CONSTRUCTING THE WELL
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.
Form GW-la
Rev 7/05
FEB 15 2013