383049_Well Construction - GW1_20100507

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3
1 WELL CONTRACTOR
£�e/A/1J fr. 1 JI ES
I Contractor (Individual) Name
.E!4LL Enos II I/I a, c 1 unipp LLC,
Well�ontractor Company Name �••
TREET ADDRESS 1731,M & IEI�CEsiEtz l tuy
1.4% tes�,E� zi L ad / yd /
City or Town ' State
(9 )- Z452-- X q9!2.
Zip Code
o (i-0044"2
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) 1,4J 1 10
STATE WELL PERMIT#(itapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Residential
DATE DRILLED `1'402'ID
Water Supply
fEr PM D
S., CO.—v.
TIME COMPLETED //-..L, AM
3 WELL LOCATION
CITY " 11I l'/e COUNTY
CC %7eGl,^tsX 1 .?c%
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
O Slope ❑ Valley ❑ Flat edge ❑ Other
(check appropriate box)
+
LATITUDE 3 )-- 'V // %
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE r� Z ,?7 r 4/4'7 '
Latitude/longitude source fa'GPS oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS) ' /�!Q n
4 WELL OWNER /' / 7 11C/F)
OWNER'S NAMEi)�YI!'l 4ES C'lr STay�C()
STREET ADDR S .O.i i�j 1� S b4 L'I
Ashe_u( Lie_ NC .Qe soly
City or Town State
ia$)- te5— Li(th
Zip Code
cYES p NO IY
O U FT
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH rDS"
b DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing
(Use "+- if Above Top of Casing)
d TOP OF CASING IS , FT Above
Land Surface'
surface may require
2C 0118
9
'Top of casing terminated at/or below land
a variance in accordancecwith 15A NCAC
✓
e YIELD (gpm) r/Z METHOD OF TEST
i.r 1•� �yf
f DISINFECTION Type l h dlr a Amount 0 7,
g WATER ZONES (depth)
FromO To From To
From �3D To From To
From To From To
6 CASING Thickness/
Depth Diameter Weight Material
From 0 To 77 Ft G /U 5:43ez !
From To Ft
From To Ft
7 GROUT Depth Material Method
From iv/� To ao Ft Conc'_'ref . Daufin,�
From To Ft
From To Ft
B SCREEN Depth Diameter Slot Size Material
From To Ft in in
From To Ft in in
From To Ft in m
9 SAND/GRAVEL PACK
Depth Size Material
From To Ft
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Descnption
fl -- 72. CA
72- 77 c5%i
11. REMARKS:
Fin
tl Q. ck.../it.f e—r✓
iVIMI 't (UIU
Information Processina Unit
DWQ/BOG
I DO HERESY 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 ERTIFIED WELL CONTRACTOR DATE
1
G(J� /V t� 5
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.
Forph
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21113