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HomeMy WebLinkAbout384985_Well Construction - GW1_20100712City or Town (158) 2-A`3-ttti Area code Phone number 2 WELL INFORMATION • RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # 29SS to, 1 LL CONTRACTOR \tn{- ' ibbi+t- ell Contractor (Individual) Name S W.e e +-'ti r \N-e-RO Well Contractor Company Name k°12- oia 3Tryl-s P-Ar IQ Street Address C� Top Bottom 1S Ft. �c-- 7.?% Top Bottom Ft State Zip Code Top Bottom Ft WATER ZONES (depth) WELL CONSTRUCTION PERMIT# C�?c�I 0 - t+01 3 OTHER ASSOCIATED PERMIT#(if applicable) t0-0018-r SITE WELL ID#(dapplicable) '4/k 3 WELL USE (Check Applicable Box) Residential Water Supply I DATE DRILLED Lo' 1 S- I 0 TIME COMPLETED I 00 AM 0 PM 4 WELL LOCATION CITY 758 C, lQx, Th (Street Name, Numbers Community, Subdiv, COUNTY (ry. rube. / .e CL�-Z1) on, Lot No , Pa 1, Zip Code) TOPOGRAPHIC / LAND SETTING (check appropnate box) ❑Slope ❑Valley (iF'lat ❑Ridge ❑Other LATITUDE N3S"24Y 7 (P"DMS OR3XXXXXXXXXXDD LONGITUDE VJ&'.3'y 1(0 2 " DMS OR 7x )0XXXXXXX DD Latitude/longitude source PS IJropographic map (locabon of well must be s wn on a USGS topo map andattached to this form if not using GPS) 5 WELL OWNER Moor, v\ L ,l/14 - Owner Name Cc-*- 'Troy 44 LQ . 9 1 t STYV e--l`_'`'( (PQ/I;EL. ' Street Address CL aLn- a NC — City or Town State Zip Code (SZ8) SN5- 8Z8o Area code Phone number 6 WELL DETAILS a TOTAL DEPTH 4Oc b DOES WELL REPLACE EXISTING WELL? YES 0 NOJK c WATER LEVEL Below Top of Casing SO FT (Use "+" if Above Top of Casing) d TOP OF CASING IS I 11 its Above Land Surface' 'Top of casing terminate at/or below land surface may require a vanance in accordancerdwith 15A NCAC 2C-0t111�8 e YIELD (gpm) J METHOD OF TEST t t iT €d f DISINFECTION Type ec,14 Amount /O©?_ 9 Top Bottom Top Top Bottom Top Top Bottom Top 3 { 9 85 _ Bottom �� BottOI Bottom Thickness/ 7 CASING. Depth Diam er Weight Matenal 8 GROUT Depth Material c Method Top` CD Bottom Q Ft X 117� SUVA," Top Bottom Ft Ones Top Bottom Ft 9 SCREEN Depth Diamete - Slot Size Material Top Bottom in in in Top Bottom Ft in Top Bottom 10 SAND/GRAVEL PACK - Depth Top Bottom Top Bottom Top Bottom 11 DRILLING LOG Top Bottom / / / / Ft in e Matenal Formation Description WATER OUF,_ inrormruon ProGessiny unit 12 EMARKS to-/5-1 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 PROED TO THE WELL 0 N- &-/to-ID SIGNAT OF CERTIFIED WELL WELLCONTRACTOR DATE j !/t U� le,%t PRINTED NAME OF PERSON CONSTRUCTING THE WELL Q,-s1'N9x �m >� - �r rye... i r�-�,.' ,-s..r ._>,�e r..-.- .-ter ze'; r-•- "c '��.'!,-,> <`_,"_� SuI mifwithin 30-days of.conipietfon to: Division of Water Onality, =Inf&tnation,Processing; iTiA6171111e1ISerylioe:benter,Aakigh,14.1C 27699-161, Phone : (919) 807-630Q,:` "-44 a Form GW-la Rev 2/09