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HomeMy WebLinkAbout388917_Well Construction - GW1_20101104RESIDENTIAL 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