386211_Well Construction - GW1_20100812

RESIDENTIAL WELL CONSTRUCTION RECORD
E.
North Carolina Department of Environment and Natural Resources- Division of Water Quail
IAN 5 2013
WELL CONTRACTOR CERTIFICATION # 2j6 (p
1 1►n c1ibbi+t--
ell Contractor (Individual) Name
Swi-A-wa-k-c4r WR P
Well Contractor Company Name
l')2 CAGL-S
Street Address
G11\1Cenr, atnO q
2. -1-1B
City or Town State Zip Code
ega 7' -t(t-7
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# LA3t L 70 1 0—CA ZL/ `1
OTHER ASSOCIATED PERMIT#(if applicable) r 7 t
SITE WELL ID Of applicable) NAP
3 WELL USE (Check Applicable / Box) Residential Water Supply l� s
/ [ DATE DRILLED S-Io
TIME COMPLETED 02 -00
4 WELL LOCATION
CITY
AM ❑ PMtif
COUNTY /3,06j'f b
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑Valley Flat ❑Ridge ❑ Other
LATITUDE "DMS OR 3x XXXXXXXX( DD
LONGITUDE " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source PS Dropographic map
(tocabon of well must be steon a USGS topo map andattached to
this form if not using GPS)
6 WELL OWNER
SL1l V tO
Owne%ii-�C�C1LOC
CDf —11 I'3.Lr1 12-C)� .
Street Address
f,
op( ki 1e1
City or Town
(1 2i ,�.S1
Area code Phone number
6. WELL DETAILS I
a. TOTAL DEPTH. S 4-6
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES
0 NO (.
c WATER LEVEL Below Top of Casing �/v FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS EtP Above Land Surface'
`Top of casing terminatecl.)ia
at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118r
e YIELD (gpm) �aMETHOD OF TEST t t reed
C_
f DISINFECTION Type e tom' Amount /0067_
Top
Top
Top
Top Bottom
Top Bottom
9. SCREEN. Depth \
Top Bottom
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK
Depth
Bottom
Bottom
9
Top Bottom
Top Bottom
Top Bottom
WATER ZONES (depth)
Top - Bottom
Top Bottom
Top Bottom
Thickness/
3 6211
7 CASING. Depth DiametereWeight At
Top Bottom 40 Ft I;OA� -t ry 4--
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top Bottom Ft Deriltsn t I
Ft chips
Ft
Diamete Slot Size Material
in in
Ft in in
I in
Bottom
11 DRILLING LOG
Top Bottom
/
/
/
/
/
12 REMARKS
Ft
ze
Material
Formation Descnption
El i/
/AUG Y 2 MU
nfor
Dln
sing Unit
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
PROy,LpED TO THE WELL 0 N-
446_`� lb
SIGNAT OF CERTIFIED % /WELL CONTRACTOR AT
fri t.%/74 L�/
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
f Li r"; r-r rty st _y4 r-
-
Submit}within 3'D_days of completion to: Division_of Water.Q!iality - Information Processing,
1517 Mali Service Center, Raleigh; NC 27699-161; Phone = (919):807-6300 <y� �r$
_:��z �,% a' �'=
Form GW-1a
Rev 2/09