380735_Well Construction - GW1_20100205

Street Address
QV or Town 1a
( .Z) (4u Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR ...f �`'
e . l C (41 JCLA,t.' i f 16
ill Contractor (1 dividual) Name 1
A.2 l t , ri.A,.. t.' 4 is i- r.;,'N. 1,,,-,'. I
Well Contractor Company Name
f t f i - r‘
hipt
ci
flc , 'uS
State Zip Code
07,,of—et) oa
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED /2 Ujo
TIME COMPLETED / �� 3 AM ❑ PM
4 WELL LOO v+�A,T_IONJ`
CITY { e 2_
COUNTY
g./itCO�Ll4�
(Street Name Numbers, Community Subdivision Lot No Parcel Zip Code)
TOPOGRAyu/IC / LAND SETTING (check appropnate box)
❑ Slop Valley ❑ Flat DRidgenn❑ddOther
LATITUDE 36 3.51 7Gy�/a- DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 "42' %Gy 42 DMS OR 7x XXXXXXXXX DD
Latitude/longitude source
(location of well must be
this form if not using GPS)
S Ofopographic map
own an a USGS topo map andattached to
5 WELL OWNER
Jelin&ems kov�ce_.
Owner Name
s/Dcctia-s C2eek
Street Ar.res
City or Town State Zip Code
( 719) _39,1- /9 6
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
aas
b DOES WELL REPLACE EXISTING WELL? YES ❑
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
d TOP OF CASING IS
e
f
jv
NO.(
FT
FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in acco ance with 15A NCAC 2C 0118/Th
YIELD (gpm) / METHOD OF TEST . 9
DISINFECTION Type , M Amount
3g0735
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diipameter Weight Material
Top t 1 Bottom 7� Ft /,f j _
Top Bottom Ft /$ -.5` Seel
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom '2, Ft
Top Bottom Ft
Top Bottom Ft
Matenal Method
e treed
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
Size
Material
11 DRILLING LOG
Top Bottom, Formation Descnp n
// % / 0 e
/ Information Processing t Init
FEB 0 5 2n»
12 REMARKS
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDAR1J�, AND THAT A COPY OF THIS RECOf�B HAS BEEN
PROVIDED TO THE WELL OWNER
ti
SIGNATURE OF CERTIFIED WELL CONT AC Ri' DATE
PRINTED NAME F PE ON CONSTRUCTIN THE WELL
Submit within 30 days of completion to. Division of Water Quality - Information Prc eJi
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
FEB 072013
Form GW-la
Rev 2/09