380734_Well Construction - GW1_20100205

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR / 1\
+II Contractor (I dividuai) Name
►.te ,,,-1Pc"4.. 1,3J
Well C'kntractor Company me
I t/ nC �-U;C4
Street Adddres j
tt r1 e V S
CV or Town 0 State Zip Code
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID Of applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED /-6 r- 02D/0
TIME COMPLETED ..1"3tj AM ❑ PM _
4 WELL LOCATI N
CITY 5 yIkJ COUNTY &/ICO ►LQ °(�
401 /eYle Haden s1C lu�►j e
(Street Name Numbers, Community, Subbivision, Lot No Parcel/Zip Code)
•
TOPOGR HIC / LAND SETTING (check appropnate box)
❑ Slope Valley (3 Flat El Ridge ❑ Other
LATITUDE 36 °35 SSS - DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 5-9 t DMS OR 7x XXXXXxXXX DD
Latitude/longitude source S [(Topographic map
(location of well must be own n a USGS topo map andattached to
this form if not using GPS)
5 WELL,QWNER
421L) SS/- 3S�S
Area code Phone number
et 4. (. CL YY1 a*:
Owner tyam to
Ii_`PTI �P e Q l� eve ►-�
Stet i4ddress
City or Town State Zip Code
6 WELL DETAILS
a TOTAL DEPTH
5- fi-
b b DOES WELL REPLACE EXISTING WELL? YES ID NO
c WATER LEVEL Below Top of Casing -7 V FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS
R
3 ,3 � 8/ �,,, 3 4
c8;y
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth a Diameter Weight
Topt' ! Bottom P 1Ft (p r,r11
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom Q Ft l` ti Yht"i
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Material
Method
q..)0
Diameter 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
Tod I Bottom
at/ FormatioenD cnptiiin /
g9 / 3SS
/
/
/
/
/
/
12 REMARKS
EIVED
FEB 05 2010
information Processing Urltt
DWQ/BOG
/l ,I /—D2-o20/0
3e RIi r" Y t/ eAi-h S 4Wil'R 5
PRINTED NAME OF PERSON CONSTRUCTING THE ELL
Submit within 30 days of completion to Division of Water Quality - Information Procesrsi t
r
FT Above Land Surface*
`Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118 }�
e YIELD (gpm) c O METHOD OF TEST_
f DISINFECTION Type P,M Amount
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
PROVII7t TO THE WELL OWNER
t
SIGNATURE OF CERTIFIED WELL CONTRA R/ DATE
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-la
Rev 2/09
FEB0 7 2013