384985_Well Construction - GW1_20100712

City 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 : [phone]Q,:` "-44 a
Form GW-la
Rev 2/09