383052_Well Construction - GW1_20100507

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of ▪ Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / i(..)
frjez_c64. li J /l a.rd ilp)Wellontractor Company Name %/ jj jj�
STREET ADDRESS t.g73I �iEI,II LEuIESiEEL IItU y
Lc/'t%i. &/Ei Z C° . a8 7'/ //
City or Town / State Zip Code
(2.43)- 5 Xy9
Area code- Phone number
2 WELL INFORMATION // tt
SITE WELL ID #(if applicable) W E I a 6 0 4?-- 001,9 (j
STATE WELL PERMIT#(itappiicabie)
1 WELL CONTRACTOR J `
/Zi 4-n) fr. (,(/ /A ES
I Contractor Individual) Name
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check
Applicable Box) Residential Water Supply (:;1,
DATE DRILLED 7' 7 - /D
TIME COMPLETED -?,r 3d AM ❑ PM p"
3 WELL LOCATION CITY 4/4-G•""✓.rM COUNTY .,p
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/l„ AI.-.a1d s .41 2-
(Street Name, Numbers, Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTVG
❑ Slope ❑ Valley ❑ Flat edge ❑ Other
(check appropriate box)
LATITUDE 3 '' 5-8-7
LONGITUDE 6- 2 37 %/ - /
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source aiEeS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4 WELL OWNER
OWNER'S NAME
STREET ADDRESS
b JPrilJeofbi ,VC_ a7R A/R
City or Town State Zip Code
( _) 7c 3- '/ j .a i
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 70r
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO D
c WATER LEVEL Below Top of Casing / f%d FT
(Use'+' if Above Top of Casing)
d TOP OF CASING IS ( FT Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 3 METHOD OF TEST
i'
to t; e)
f DISINFECTION Type Amount JZ
g WATER ZONES (depth)
From ,.14( To From To
From 621)-12 To From To
From To From To
6 CASING Thickness/
Depth Diameter Weight Material
From 0 To `-#4, Ft Z,IZf S'/ ,,G✓�
From To Ft
From To Ft
7 GROUT Depth Material
From ip To a 0 Ft Conic ref e.
From To Ft
From To Ft
Method
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 Size Material
From To Ft
From To Ft
From To Ft
10 DRILLING LOG
From To
0— c//
e-//- miry
v1 -
11. REMARKS:
Formation Descnptton
6144
Ski/
1-04
MAY 7 2010
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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 PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED CONTRACTOR DATE
•
-'41) fJJ/yes '
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.
D
tit
" M `Form GIN-1a6
FEB 25RJ1 I0 Y