386213_Well Construction - GW1_20100812

RESIDENTIAL WELL CONSTRUCTION RECORD
ELC
JAN 5 2013
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 LL CONTRACTOR
\en4- � b ib-H--
ell Contractor (Indmdual) Name
Well Contractor Company Name
PY d
Street Address
G\Nar\r,c no c
City or Town I
(& Z --q8— t l
Area code Phone number
Nc 2A-1-16
State Zip Code
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# YM Y LZi L7 19 I
OTHER ASSOCIATED PERMIT#(if applicable) r 7�
1-
SITE WELL ID #(d applicable) `/ A . 7
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED '7' / 9 - /0
TIME COMPLETED 3 - b U
AM PM[ '
4 WELL LOCATION' _ /,,
CITY �i/,�a/i/`e / � e COUNTY &
ilint,/te
(Street Name; Numbers, Community, Su No,vZo Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope [Valley ile}FIet ['Ridge ❑Other
LATITUDE
° " DMS OR 3x xxxxxxxxx DD
" DMS OR 7x xxxx00000( DD
❑Topographic map
wn on a USGS topo map andattached to
LONGITUDE
Latitude/longitude source
(location of well must be sl
this form if not using GPS)
PS
LL OWNER
an/I /7Lceet)
Owner Name
Str t Address
City or Town State Zip Code
(81S) 35-7-9►L/
Area code Phone number
6 WELL DETAILS
a. TOTAL DEPTH
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO*
c WATER LEVEL Below Top of Casing ' FT
(Use °+" if Above Top of Casing)
a
d TOP OF CASING IS 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) METHOD OF TEST {t11ined
f. DISINFECTION Type Ce /'1' Amount [ 00-7_
WATER ZONES (depth)
Top Bottom Ftm
Top Bottom Ft al (p.5
Top Bottom Ft
g
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter ern Weight Pkg.-
Tor-e,..Bottom Ft cv- �:;l c:_
V.6213
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Screen
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
11 DRILLING LOG
Top Bottom
' a
12 REMARKS
ze
Material
Formation Descnption
/REUEbVED
AUG 1 2 2010
Information
owtvs
1 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,IpED TO THE WELL OWN^
/41
7-Z3-iD
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Y,=�.s- 4y" spy 5' i:3
5uhtmit within 30 daysof-completion to: Division of Water Quality _ hiforniagon Pfio�essitiy;
1617 Mali $ervtce Center;Ralei h-NC 2T 99-1 1 P '''``''- 't
g , 6 , 6 , hones (919�"807-6300n
Form GW-la
Rev 2/09