384055_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 t aa
13 i is Y 0 l', t cailA, -Sa.,i 1 i 16
Vi(ell Contractor (Individual) Name
Well Contractor Company Name
Street Address
Cip or Town State Zip Code
(U4i) idp,5 -
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 7tU 11% 1 [)1l
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL. USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED C - / C/
TIME COMPLETED li. AM ❑ PM
4 WELL LOCATION
CITY t
r' ; ilk- k! t "� � OUN T Y .J ',� lid`
l-/5 /l-N,
(Street Name Numbers, Community, Subdivision, Lot No Parcel Zip Code) /
TOPOGRAPHIC / LAND SETTING (check appropnate box)
Slope ❑Valley D Flat O Ridge ❑Other
LATITUDE 36 '35 (° DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 °
Latitude/longitude source
(location of well must be shown'Sn a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER;
S?tl' DMS OR 7x XXXXXXXXX DD
Qfopographic map
Owner Name -. 1 i
Sttt Address
City or'Town i State Zip Code
1 k.uc
{ ` 4
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 376
b DOES WELL REPLACE EXISTING WELL? YES ❑ NOi , —
c
d
e
f
WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
TOP OF CASING IS
,/)'
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
YIELD (gpm) / L (' METHOD OF TEST t G
Amount
DISINFECTION Type }
, �j
( -/
3,a405e
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Tops I Bottom /�j / Ft r,f #,� r 9_
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom Ft C t"I"he
Top Bottom Ft
Top Bottom Ft
Method
�(?t....Se'(1
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 Size
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
Material
11 DRILLING LOG
Top Bottom Formation Descnp n
1/ / �7/ (�` e e_ I i d
12 REMARKS
Ml`( `� $ 7010
F „ Uinc messing urea
ifiiu, �.
DWQ1BJG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDAR1 , AND THAT A COPY OF THIS RECORD HAS BEEN
PROVI,3 TO THE WELL OWNER
4'-1 v /.
SIB TURE OF CERTIFIED WELL CONT C R//' DATE
\!f
ff / r/
l� /� ' C \ f �i, �,\, LG��J/%.,-/
PRINTED NAME OF PERSON CONSTRUCTING -THE WE!/L
Submit within 30 days of completion to. Division of Water Quality Information Proc
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone] e i t..
Form GW-la
Rev 2/09
JAN 1 8 2013