384988_Well Construction - GW1_20100712

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3SS (,p
1 'L
CONTRACIRR.
b b;it
ell Contractor (Individual) Name
S .f e -\,►a4-(4e \N-Q.9
Well Contractor Company Name
1a 2. 01, y s 1),Y 12c1
Street Address
G1Nary- Lr c c'
City or Town State Zip Code
egaa) i�1f3-((li
Area code Phone number
2 WELL INFORMATION WELL CONSTRUCTION PERMIT# WEL IO-00180
OTHER ASSOCIATED PERMIT#(it applicable) Noc-
k
SITE WELL ID #(if applicable)/
3 WELL USE (Check Applicable Box) Residential Water Supply tars.
DATE DRILLED (.0-2-8— I D
TIME COMPLETED 2 -_7173 AM 0 PM%
4 WELL LOCATION:
CITY Vl teGC1%t✓ V1I e_ COUNTY T3Lat hWChr ,/
AIrnor'cl H1,11 19�e.S Le- 1(p
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley lat ❑Ridge ❑Other
LATITUDE I.) 3s • t.{5" 7Le 4 " DMS OR 3x XXXXXXXXX DD
LONGITUDE [ Z ° 7j0' i CD " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source
(location of well must be sl
this form if not using GPS)
3PS Dropographic map
wn on a USGS topo map andattached to
5. WELL OWNER
Ntavl i LOLA ?CD nei.er
Owner Narfte
GI ,614117 na.v)
1 St et Address 71
..-1 ✓I,/ (J / vt 4,2(% r 7
City or Town State Zip Code
1, 7s-- 7997
Area code Phone number
6. WELL DETAILS
a TOTAL DEPTH. o�
b DOES WELL REPLACE EXISTING WELL? YES 0 NO
c WATER LEVEL Below Top of Casing le 0 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 �s leP Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance - with 15A NCAC 2C 0118
e. YIELD (gpm) tp �t_. METHOD OF TEST•yt t/r led
C..
f. DISINFECTION Type {A' Amount 007
3
V88
g WATER ZONES (depth) n��' 2 7(1l)
Top Bottom Top BottoM
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth DiametereWeight ^Matenat
Top Bottom 30 Ft i�! c CYT V L-
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenat Method
Top Bottom <90 FL5Qr t Sex --en
Top Bottom Ft t `05
Top Bottom Ft
9 SCREEN- Depth Diamete Slot Size Material
Top Bottom _ in in
Top Bottom Ft in in
Top Bottom i in
10 SAND/GRAVEL PACK
Depth ze Material
Top Bottom
Top Bottom
Top Bottom Ft
11 DRILLING LOG
Top Bottom
12 ' EMARKS
Formation Description
ATER QUAL Y
Inform.- Ion riu
(e-2 23--to t a v►Le-'a .
• 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
PRO'I{pED TO THE WELL 0 N
Ce-29—tc�
SIGNAT OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
s— _. =e
Submit within,30 days cif completion -to: DivIsion'ot Water Quality - Infor nation Pfi>cessing;=:
1617 Mad Service Cenler,-Raleigh, NC 27699-161,=Phone [phone] a " <
Form GW-1 a
Rev 2/09