382573_Well Construction - GW1_20100420

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR /
ell Contractor (( vidual) Name _
L s r' S /`, �, :; t 1,
Well Contractor Company Dame
Street Address
1
C) t J�-1; to [)
Cibr or Town 1'
( ) 64S —
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# tOV -rose/3
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED .3 —/5 c2 /d
TIME COMPLETED ' I' AM 0 PM
4 WELL LOCATION/
CITY fi CP//�. COUNTY a;La-L
d 9 -4-k.e4 ' / t-tok.. / - Ade,,
(Street Name Numbers, Comi f nity, Subdivision, Lot No Parcel Zip Code)
,OGRAPHIC / LAND SETTING (check appropnate box)
Slope DN./alley oFlat DRidge ❑Other
LA ITUDE 36 ° -3j V 33 (l `6 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 ° n ' S 9" DMS OR 7x XXXXXXXXX DD
Latitude/longitude source S OTopographic map
(location of well must be own n a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
�l /(6
( ) 9-, '93'2
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
Owner Name
Stre Address
/L(/ V
City or Town � e„ ����
State Zip Code
i D3'
b DOES WELL REPLACE EXISTING WELL? YES ❑ N
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
d TOP OF CASING IS
State Zip Code
g
Top
Top Bottom
Top Bottom
WATER ZONES (depth)
Bottom
7 CASING Depth Diameter
Top t 11 Bottom d2 / Ft /0_ fri
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top Bottom .2O Ft
3 1.1 9
i QS, 4
e/
Top Bottom
Top Bottom
Top Bottom
Thickness/
Weight Material
Material
c me14
Top Bottom Ft
Top Bottom Ft
Method
eft
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
% / Cid
/
12 REMARKS
Size Material
Formation Descnp n
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDA , AND THAT A COPY OF THIS RECOHAS BEEN
PROVRE TO THE WELL OWNER
FT Above Land Surface' iAte.._.
*Top of casing terminated at/or below land surface may require �? ,, 99 22
a variance in accordance with 15A NCAC 2C 0118 ` OF C ` /' DATE (✓ ���
et
SIGNATURE OF CERTIFIED WELL CON AC R�' DATE
e YIELD (gpm) D� ' METHOD OF TEST `..e %1e22 r,G 71 / et -FL la i C /,
f DISINFECTION pe , fj Amount PRIICCNTTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to. Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone]
1
/16
FT
Fo F11$15 2013
Rev 2/09