388917_Well Construction - GW1_20101104

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3GJE> (.p
1. LL CONTRACTOR
1tri.1-• 1ibbiTh
ell Contractor (Individual) Name
SwLe-VW 04-e4r \N
Well Contractor Company Name
Street Address
S NcarynconoQ 1 I•1c.- 2 Y e)
City or Town State Zip Code
(l) 2eS-i tri
Area code Phone number
2 WELL INFORMATION-
WELL CONSTRUCTION PERMIT# VN E L Zvi 6 -�1 Cj
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(d applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED IC) —`[3- t o
TIME COMPLETED ! / ' %0 AM PM D
4 WELL LOCATION
CITY EiCi , ri(L
COUNTY fl ion be I
ts:L (Street Name, Numbers Com ity u divisi n, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
DSlope ❑Valley Ei.Elat 0 Ridge 0 Other 11 DRILLING LOG
LATITUDE N33 ° -I 3(02 " DMS OR 3X XX)0XXXXX DD
LONGITUDE W82"/3 ' 303 " DMS OR 7X.XXXXX0:XX OD
Latitude/longitude source PS DTopographic map
(location of well must be s wn on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
cnn i P_ Mott k e
� Y � I
ner Name
2-01
S reetAddress� ��
aT pv r, S St . 29
City or Town 9 1 State Zip Code
511-2g3c
Area code Phone number
6 WELL DETAILS.
a. TOTAL DEPTH 3 2.Si
Top Bottom
/
12 REMARKS
r &..n J
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING. Depth //�� Diameter SCrvW�eight
Top Bottom (o 1 Ft. (A! t
Top Bottom Ft
Top Bottom Ft
MMa``tenat
rV L
8 GROUT Depth Matenat t�� Method
Top9 Bottom Ft ile-Screzeri
Top Bottom Ft Oil I p.5
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
Top Bottom
Top Bottom
Top Bottom Ft
Material
Formation Description
J
A !�
b DOES WELL REPLACE EXISTING WELL? YES 0 NO P .
�1 I D0,► kRREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing 0 f')'nFT 0 ACCORp NCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use "+" if Above Top of Casing) -4W,0 �S f�,�I d. AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASING IS 15P Above Land Surface*'c
'Top of casing terminate at/or below land surface may require
a vanance in accordance with 15A NCAC 2C »t011�ied
0118
e YIELD (gpm) r METHOD OF TEST t rY
f. DISINFECTION Type CC fi Amount /t 0-7_
J
DA
P EDTOTH>:WELL O N
SIGN/(7UF' OF CERTIFIED WELL CONTRACTOR
/0-- /o
DATE
(it,/
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
. -.,,Ir f { ti sir �,� _a--r... - >: 7-1Submitwithin-30_days`of compietion-to: Division'of Water Quality _information Processing
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :_(919) 807-6300.45
13
Form GW-la
Rev 2/09