384386_Well Construction - GW1_20100604

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qu
WELL CONTRACTOR CERTIFICATION # 2 SS
1 LL CONTRACTOR
`rnq- 'elf( b bi+f-
ell Contractor (Individual) Name
Sw.e.e+-\i tJ -kkr \ kvQ
Well Contractor Company Name
Street Address
G\Narve-,cAnoq
City or Town
(z$) 2'g-i(ii
Area code Phone number
"NC- 2Pi-1,
State Zip Code
2 WELL INFORMATION-
WELL CONSTRUCTION PERMIT# W E 1- ct1 ?-c 003 2-3
OTHER ASSOCIATED PERMIT#(it applicable) 7,1 A -
SITE WELL ID Cif applicable) / AC 7
3 WELL USE (Check Applicable Box) Residential Water Supply i
DATE DRILLED t O
TIME COMPLETED (a ' OC7 AM ❑ PM la.
4 WELL LOCATION
CITY X •
COUNTY filet-iblala
1 t 0L 0_121F"CiTh P •
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley (Flat ❑Ridge ❑Other
LATITUDE i 3 S " ' '/ Ff 7 "DMS OR 3x XXXXX(XXX DD
LONGITUDE ,‘")cb22 1} l ' L (i " DMS OR 7X XXXXXXXXX DD
Latitude/longitude source PS Oropographic map
(location of well must be s wn on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Owner Name
ILjL
vonk..,c-, C e`_ 17 d
Street Address
CaJel
City or Town State Zip Code
( R2Ss) -7o-1 - -9045
Area code Phone number
6 WELL DETAILS- c
a TOTAL DEPTH 4E3S
b DOES WELL REPLACE EXISTING WELL/ YES 0 NO C%
c WATER LEVEL Below Top of Casing 40 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 41 F Above Land Surface*
'Top of casing terminate at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118-
e YIELD (gpm) c METHOD OF TEST t -! reed
f DISINFECTION Type CC.. Amount /0O7_
Top
Top
Top
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
Top Bottom Top
384g86
Bottom
Bottom
Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top"-CrBottom 100 Ft �Y¢ c. rn�1 /A C--
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom O Ft 13erklitflt SCr1
Top Bottom Ft O(1135
Top Bottom Ft
9 SCREEN- Depth Diamete - Slot Size Matenal
Top Bottom in in
Top Bottom Ft in in
Top Bottom i in
10 SAND/GRAVEL PACK
Depth
Bottom
Bottom
11 DRILLING LOG
Top Bottom
/
/
/
/
ze
Material
Formation Descnption
r'
JAK ? tA 2013
12 EMARKS
�� "'4-/O // on yZr-7 [J/ Me f
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
PROV.IAED TO TH WELL 0 N
SIGNAT OF CERTIFIED WELL CONTRACTOR. orN R DATE
PRINTED NAME OF PERSON CONSTRUCTINGHE EVE -"'
;Submit within-30-days'of completion to: Division of Water Quality -{ Tlhformatioi1 Processing; /afar rtatio Form GW-la
- (617. Mail Service Center, Raleigh;=NC 27699-161, Phone • [phone] T `_ , - r- ` �;_' . `; L�l�r , f�LWflev 2109
2010