381598_Well Construction - GW1_20100305

LC
OCT 11 S 2010
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 / 4k)
3 °' 8
1.1LL CONTRACTOR
j i 44 A) jj . LC/ i ‘itr ES
1 Contractor (Individual) Name
.Ei // CisA6 /2 fEII a/it/Rola, LI.C.
Well ontractor Company Name / 1
STREET ADDRESS 41731 AO LElek-s t I///L�
Wy
City or Town State
Area code- Phone number
2 WELL INFORMATION
Zip Code
SITE WELL ID #(if applicable) LW & t-- abb _ boil $
STATE WELL PERMITAptappticabie)
DWQ or OTHER PERMIT Wit applicable)
WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED ' 2,- "/4;
TIME COMPLETED 1 /• J 7 AM Er PM ❑
3 WELL LOCATION
CITY 4.• e COUNTY .2:4'c a t ie
CO-rnlr1 / C
(Street Name Numbers Community Subdi is on Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
latiope ❑Valley ❑ Flat D Ridge
(check appropriate box)
LATITUDE 3 � yl. 21 '
LONGITUDE rr 1 4 1' ?35-'
❑ Other
May be in degrees,
minutes, seconds or
in a decimal forrnat
Latitude/longitude source r5 PS EiTopographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4 WELL OWNER
OWNER'S NAME
TREET ADDRESSt
LeI cese_t
City or Town
(�a�3 )- � ce —1c)3
Area code - Phone number
5 WELL DETAILS ��
a TOTAL DEPTH
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO D,
e WATER LEVEL Below Top of Casing V
(Use'+' if Above Top of Casing)
d TOP OF CASING IS 1 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) / 0 METHOD OF TEST
FT
f DISINFECTION Type G' Amount 4P "c:
g WATER ZONES (depth)
From 31� To From To
From 404./4% To From To
From To From To
6 CASING Thickness/
`/ Depth Diameter Weight Material
From To 'e d Ft 4--l..- ✓�-s (/ -•'1-C
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 To a Ft COX rtfle• ?mu/10 j
From To Ft
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 Size Material
From To Ft
From To Ft
From To Ft
10 DRILLING LOG
From To
V 2/
Z/-14
Lam• Sekr,
11. REMARKS:
Formation Description
Oft. y
shl.l
4-1
drat,
1)
itIAR y 201n
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U-nt
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE WRH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Peves
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