388052_Well Construction - GW1_20101007

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 Zp
1 LL CONTRACT R
ell Contractor (Individual) Name
Sw-ee a-kr wes
Weil Contractor Company Name
t'212-
Street Address
GNivarvr,ckno q
City or Town
(Z•3) Z,98-tits
Area code Phone number
t'k 2.-B
State Zip Code
2 WELL INFORMATION []
WELL CONSTRUCTION PERMIT# Vt E (.2b ! Ob II b
OTHER ASSOCIATED PERMIT#(It applicable) kVA-
SITE WELL ID #(if applicable) t `/
3. WELL USE (Check Applicableli�
cBox) Residential Water Supply l
DATE DRILLED -1 -1 O'lip
TIME COMPLETED I d ' b AMp PM 0
4 WELL LOCATION �,
CITY S W e ii iu no
/a COUNTY J,(.JJ'i(b�1&'
J/' ml"/l,/)J(1 (/1-ew Ped
(Streetme, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope DVaie ❑Flat ❑Ride DOther
LATITUDE "2' 34 f p " DMS OR 3x XXXXXXXXX DD
1,-LONGITUDE* "2. ' Z I " DMS OR 7X.XXXXXXX0( DD
Latitude/longitude source iPS Oropographic map
(location of well must be sry'own on a USGS topo map andattached to
this fort if not using GPS)
5 WELL OWNER
a /4fl NZ/499//,l])
ner am e
PS- m'/7i" hi as 1 ,14,4) 9.
treetAddr s
^l�r 7101/66( /V e.- 2 Y-77 V
pity� oy Town State Zip Code
f?'? 9e, /mo) " Jush ZEj
Area code Phone number
6 WELL DETAILS.
a TOTAL DEPTH
b. DOES WELL REPLACE EXISTING WELL? YE■NO ❑
c WATER LEVEL Below Top of Casing 0 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS OF Above Land Surface*
*Top of casing terminate at/or below land surface may require
a vanance in accordance with 15A NCAC 2C -011118
e. YIELD (gpm) / ti �MEETHOD OF TEST t t riled
C., f DISINFECTION Type C., f'i- Amount /067_
g WATER ZONES (depth)
Top
Top
Top
7 CASING Depth
Top ' Bottom
Top Bottom
Top Bottom
rk p
Bottom Top Bottom
Bottom Top Bottom
Bottom Top Bottom
Thickness/
Diameter Weight Material
te0o Ft. Si -11 PVC --
Ft
Ft
8 GROUT Depth Matenal
Method
Top Bottom OCr Ft ii114r Sejje1
Top Bottom Ft OAle.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 ze Material
Top
Top
Top
Bottom
Bottom
Bottom Ft
11 DRILLING LOG
Top Bottom
/
/
Formation Descnption
0 Q' 1
23{6 2 C
cu �a
li 'L_ 4_- u @t�
T ri ,_010
intornia�i�-5:tity Unit
,cir tc3
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,1flED TO TH WELL 0 N
SIGNATUF'1E OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1,r---- ert_.i,s.-^ t"ot s—r .._-.r ^r ,_...y-.-•__ ��_'�a''"''���%z"',v';s `�: ; :.:`r�.' -,' 3'Ut''t�c= "'"
Submit�within -30 days of completion to- Division'of Water Quality :-Information Pfocessing, ;
1617 Mail Ser'vice'Center, Raleigh; NC 27699-161, Phan.: (9191807-6300
.4. - _ems ,_ J .c-
Form GW-1a
Rev 2/09