386209_Well Construction - GW1_20100812

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ,SS (p
1 WELL CONTRACTOR
Neil Contractor (Individual) Name
Si w 4, \N-P
Well Contractor Company Name
19)2 cIctrpS JAY 12-Cl
Street Address
City or Town State Zip Code
ea.a 2-49A—(1 -7
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# c20 ( r) - Or)as-a.
OTHER ASSOCIATED PER- MIT#(if applicable) 1;i4/fri--
SITE WELL ID #(if applicable) k
iN ' q'(ei,g0a9o-1oo
3 LL USE (Chet Applicable o) Residential water Supply ti%
DATE DRILLED —1--g .-1O
1'1c--2 B
TIME COMPLETED Z'• DO AM ❑ PMgi
4 WELL LOCATION
CITY A 1 Ve.._ COUNTY uCtar'1b
Wo C-DLQ nh 12 (
(Street Name, Numbers Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
['Slope DValley xylat ❑Ridge DOther
LATITUDE (\ 2 °31 ' ) 244 " DMS OR 3x XXXXXXXXX DD
LONGITUDE r' 5i 2 ° Zr/' ' ( " DMS OR 7X XXXXXXXXX DD
Latitude/longitude source PS ❑topographic map
(location of well must be s own on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
p 1 ULI 1 S
Owner Name
Street Address
AcJR.IzU UL.p ( N c�
City or Town State Zip Code
W&yi
cca&S)30-.2(4-73 .
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
J I
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
d TOP OF CASING IS Above Land Surface*
'Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C-y01-118
e YIELD (gpm) METHOD OF TEST t : rued
/
f. DISINFECTION Type C�L Amount /007.
YE ❑ NO
D FT
Top
Top Bottom
Top Bottom Ft
9
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth ((,,}} Diameter Weight �M�aftenal
Top Bottom -IS Ft fir T'
M20►9
WATER ZONES (depth)
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top C) Bottom O Ft 1t� ,, ScrL€ nJ
Top Bottom Ft al11�
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
Bottom Ft
11 DRILLING LOG
Top Bottom
Jam/
4
/
/
/
/
12 EMARKS
ze
Material
Formation Descnption
AUG 1 2 2010
Informa
DWQ/BO
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
PR!� H ` N
DO T
SIGNATUFCE OF CERTIFIED WELL CONTRACTOR DATE
414e-
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
;T ter",. • i a-;�: - --� _ems-,z?_sft .. �,-....�$_e _'''� c--- x..r,�.� ��`.. _'s
F�-Submitwithin-30 days of completion to: -Division of Water Quality Information P rocessing, 01617 Mail Service Center, Raleigh, NC 27699-161' `Phone •-(919)`-807-6300;1 ' = r' `
_
"s_
ng Unit
Form GW-la
Rev 2/09