384051_Well Construction - GW1_20100323

a Cs, 11 eLima lk �'K
C or Town State Zip Code
( J) ) 19S-
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# ^FIV gCi " CC` Ifs
OTHER ASSOCIATED PERMIT#(if app( cable)
SITE WELL ID #(tf applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply (Jt
DATE DRILLED 5-- t:' • E O
TIME COMPLETED
4 WELL LOCATION
CITY eJiw e
sA
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR 1 g WATER ZONES (depth)
`-1.) i 0_.' , C' V -) tA. C 6 T11 .Sail `sat 16 Top Bottom Top
i c C . 1 Top Bottom Top
', 1 1? - il`` Ad.:-E I, 1-f -' 1 t Top Bottom Top
Well Cpntractor Company fume
I t AS j „r C ati �-'�,) i'
Street Address i n
Well Contractor (Individual) Name
Ui,Cru
AM El PM
COUNTY / l,i(crr:jcf
6 AiCidej2/7
(Street Name Nut4ibers Communtt ' Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
uo❑ERidpother
LATITUDE
❑Valley 36 Flat ZE ge T ^DMS OR 3x XXXXXXXXX D
LONGITUDE 75 ° C2 '73.- " DMS OR 7x XXXXXXXXX D
Latitude/longitude source SDfopographic map
(location of well must be Shown n a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
f� l� „WC-04 ,, j c.
Owner Name
Street Address
City or Town
((•-,; 8 ) ((77- e7C/
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH ,,2'!S
b DOES WELL REPLACE EXISTING WELL? YES ❑
c WATER LEVEL Below Top of Casing /CZ
(Use "+" if Above Top of Casing)
d TOP OF CASING IS
A, c_ // S
State Zip Code
NO/
t
FT
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 OM) ,�( METHOD OF TEST 6� . e;_
f DISINFECTION Type r , 14' Amount /f
1
D
D
7 CASING Depth Diameter
Top Z Bottom 7I Ft
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 2a Ft
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Material
L t r1\e'1
Bottom
Bottom
Bottom
3,.4051
Thickness/
Weight Material
4/ ,fir, -
Method
�( .w I e
Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft to 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 Formation Descnp n
f / lc c` e
12 REMARKS
T'vE<,
FhiP
MAY 2 8 2010
Inforfnaaon, p' oc =ssing Unit
DWQ/p30(y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARI�, AND THAT A COPY OF THIS RECOD HAS BEEN
PROVIDtD`TO THE WELL OWNER
ri "" '`' 4 = ✓ ,� j -i- It"
SIGNATURE OF CERTIFIED WELL CONT'AC R//' DATE
PRINTED NAME OF PERSON CONSTRUCTING T
Submit within 30 days of completion to: Division of Water Quality - Information Processing )i#„+, Ft
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone] g'_ t t .= RGW-la
Rev 2/09