388915_Well Construction - GW1_20101104

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2C' Lp
1. LL CONTRACTOR
`tn4- 'Rt b bi+r
ell Contractor (Individual) Name
S w•fi t'P i 4-e r W-EPS
Well Contractor Company Name
19)2C6�+rn—s'R,r
Street Address
1jQrw- CAtflQ41
City or Town
(P.57 ) Z'7 - l l l i
Area code Phone number
r1C-- 21;r1
State Zip Code
2 WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W GL 2 c� lc,-c cJo
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(if applicable) N/ k 7
3. WELL USE (Check Applicable Box) Residential Water Supply ID,.
DATE DRILLED /a— 2.—I 0
TIME COMPLETED /Z OD AM 0 PM,
4 WELL LOCATION
CITY t7 ,I 1t(\/ 1 c.v.)
COUNTY (ll(i ri 10,12y
r6�5 � nvir
(Street Name, Num rs, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley Bf-Iat B.Ridge ❑Other
LATITUDE "DMS OR 3x XXXXXXXXX DD
LONGITUDE " " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source PS ['Topographic map
(location of well must be s wn on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
I aYri_!
Owner Name 1
tree Address /
t � )1 e 2B�. /
City or Town State Zip Code
4- I i
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
Top Bottom Top
388915
Bottom
Bottom
Bottom
Thickness/
7 CASING- Depth ,� Diameter Weight
Top- l../ Bottom V Ft (/f-
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom Ft
Top Bottom Ft
Top Bottom Ft
MMa``tenai
TvL
Material Method i
ips
Screen
9 SCREEN- Depth Diamete Slot Size Material
Top Bottom
Top Bottom Ft in in
Top Bottom i in
10 SAND/GRAVEL PACK
Depth ze Material
Top Bottom Ft
Top Bottom
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/
/
Area code Phone number
8 WELL DETAILS.
a TOTAL DEPTH
7os
b. DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
a
/
12 EMARKS
Formation Description
IM1
1
ne
Przc
/V 111
YES ❑ NO 14.
I DO HtREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ldti ORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
Y OF THIS RECORD HAS BEEN
67) FT
' Ifarn STANDARDS AND THAT A COP
tattOri l Q PRO ED TO TH WELL ON
d TOP OF CASING IS c
ii� Above Land SurfaceDWQ/$r�Gs/
*Top of casing terminate at/or below land surface may require
a vanance in accnrrtance with 15A NCAC 2C 0118.�
e. YIELD (gpm) �- METHOD OF TEST t t Med
f DISINFECTION Type ec fi- Amount /O)7_
SIGNATOF CERTIFIED WELL CONTRACTOR
/U-S- D
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
_ t•- -...' ' y x,�:.-- - r TF.� .g , �.,�,c i„m s -r:,, ^ "- F-v.=-..-->_ '-.>- i t- 5�.= a �� _��.--�..--; 5 _ x..� rrj r r-7,
Suhmit withig 30_days_' of, completion to: Division of Water>(uality Y Information Processing;
1617 Mail Service Ce h n 919 8 7
nter, Raleigh, NC 27699-161ti P o e :( r �' 0 �300-^ ,{ "
_Y?''� _s.* �_t =-�. �.`.. t�u� 1�.>• .�..ft i vii`.F.t' . e -. +E-i-
Form GW-1 a
Rev 2/09