380381_Well Construction - GW1_20100615

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR J ,
& ,1-A) k. GU i� ES
ir1 Contractor Qndividual) Name
elii.i6A6 c JE/l afid?Wnp, a —Co
Wellontractor Company Name
STREET ADDRESS
/'CES JE/- dt C' a:7q
City or Town / State Zip Code
Area code- Phone number
2 WELL INFORMATION /�,�
SITE WELL ID *Of applicable) LL.)I5 am. ap - 1(UV4(
STATE WELL PERMIT#(irapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Residential Water Supply IF
DATE DRILLED /2-4'2-��' —
TIME COMPLETED • (-V AM p PM �Y/
3 WELL LOCATION
CITY ec}re//e, COUNTY 4—k
• r 5/
(Street Name, Numbers, Community Subdivision Lot No
TOPOGRAPHIC / LAND SETTING�
❑ Slope D Valley ❑Fiat (drudge ❑ Other
(check appropriate box)
LATITUDE 3 .31. 7 iL
LONGITUDE 'P L 4/G 4,1e
Latitude/longitude source er6PS
Parcel Zip Code)
May be in degrees,
minutes, seconds or
in a decimal format
❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form i1 not using GPS)
4 WELL OWNER
OWNER'S NAME /v�1.J 8R.-gyj /V, Rq+
STREET ADDRESS Jam• .�-I �GG,77r/-
n die-✓
City or Town State Zip Code
c$ ) 7 '/- /7.5"'/
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES c) NO
e WATER LEVEL Below Top of Casing 4;
4
1 FT
(Use'+' if Above Top of Casing)
2 it-s—
d TOP OF CASING IS / FT Above Land Surtace'
' Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
a YIELD (gpm) ) METHOD OF TEST
380381
f DISINFECTION TypeC64-'1
Amount
g WATER ZONES (depth)
From / /S' To From To
From / 74) To From To
From To From To
6 CASING Thickness/
De49 Tot 5-3 Ft L,/l t NZ /
Diameter
From
From To Ft
From To Ft
fidatenal
7 GROUT Depth Material Method
From p To aO Ft Co/ierele ?d9L(fvlyQ
From To Ft jj
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From To Ft in in
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth
From To
From To
Ft
Ft
From To Ft
10 DRILLING LOG
VmFro
1/10
7-y )
5_J Z,,l
11. REMARKS:
Size Material
Formation Description
L 4-r
5.4
nl r
lntp
Mrt1oa1 ProCassrng unit
1 DO NEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W TH
ISA NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF 'MIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OFRTIFIIEDWELL CONTRACTOR DATE
Z/44N 1k LLJa /yes
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn. Information Mgt.. 9 ; , it
S
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568. FEB 4 s 201
3
Form GW-1a
Rev 7/05