381911_Well Construction - GW1_20100323

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR
f Lak,[�K ems:k F)
Well Contractor Company fame
I n c i-u,.)a,l ) d
Street Address
C or Town State Zip Code
(`iS2) 4( — Q
�,t
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
-FL
g WATER ZONES (depth)
Top Bottom Top Bottom
° Top Bottom Top Bottom
3
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
CITY
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight
? Top !� Bottom l° Ft r� c,� 1
Top Bottom Ft
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED G2 —al— 70
TIME COMPLETED of 3 a AM ❑ PM�j
4 WELL LOCATION vv
3 LJQ.ru�p,.,aa.. COUNTY '01.01,Combe-
(Street Name Numbers, CommunSubdivision, Lotn Zip C de)
T OGRAPHIC / LAND SETTING (check appropnate box)
Slope ❑ Valley ❑Flat ❑Ridge Other
LATITUDE 36
"-�5 'S� �',t/ "DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 0 '
DMS OR 7x XXXXXXXXX DD
Latitude/longitude source S Qfopographic map
(location of well must be s own n a USGS topo map andattached to
this form if not using GPS)
5 WELL(.1 NER
Owner Name
�l wJQ U'_
Street Address
1,0 Ct/11/Q/KOk-
City or Town State
Area code Phone number
6 WELL DETAILS-
a TOTAL DEPTH
a65—
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO,
c WATER LEVEL Below Top of Casing tQ 0 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS
�`—
ace*
`Top of casing terminated at/or beloFT Above Land w land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) I S METHOD OF TEST . &
f DISINFECTION Type '1", I')) Amount 1-5
1
Top Bottom Ft
8 GROUT Depth
Top 0 BottomI Ft
Top Bottom Ft
Top Bottom Ft
Material
9 SCREEN Depth Diameter
Submit within 30 days of completion to. Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone]
Material
Method
Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/ /i1)
/D / �T (vS
/
/
/
12 REMARKS
Formation Descnp n
_• V 9y�
\A\ 4�"sOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDA , AND THAT A COPY OF THIS RECOF�� HAS BEEN
PROVIDt TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CON A R./� DATE
to kiL i c 1 e kkk .. a/Lo ,ens
PRI ED NAME OF P RSO CONS R CTING THE VVELL
TIVIS
orm GW-la
FEB 29 "ZIAB
ell Contractor (Individual) Name �1