382574_Well Construction - GW1_20100420

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL COATRACTOR- //
Well Contractor (Individual) Name
Well contractor Company NSme
/t s
Street Address 7
City or Tdwn d
(f. r) h46-2Q
Area code Phone number
2 WELL INFORMATION•
ne GPM,
State Zip Code
WELL CONSTRUCTION PERMIT# OD ( — })S'
OTHER ASSOCIATED PERMIT#(rfapplicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED 3 1 �2' t
TIME COMPLETED �1 G AM O PM
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth / Diameteriz-
Weight atonal
at Tap Bottom / �J Ft LP at / LL°
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Top 0 Bottom 40 Ft eel Mt
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Method
ed
Diameter Slot Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
in
in
in
in
in
in
a WELL L CATION 10 SAND/GRAVEL PACK
r Depth Size Matenal
CITY( II_` r �/I tf l' i I j ( COUNTY � vr, e C-7%,12 e.... Top Bottom Ft
t li'', / CI -a Cg e `t_ fi ()Cu7 ke,CeSfe 11CTop Bottom Ft
(Street Name Numbers Corn unity, Subdivision, Lot No , Parcel Zip Code) ' Top Bottom Ft
TOPOGRAPHIC / LAND SETTING (check appropnate box)
0Slope4alley ❑Flat ❑Ridge ❑Other
LATITUDE 36 ° 3 i ' 53"DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 ° C),-' i fT 3 ��( " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source
(location of well must be sho
this form rf not using GPS)
5 WELL OWNE„R-D
Owner Name /
Street Address
i s4-t r �i
City or Town
(S� S) 2 PI — 9/3
rip
Area code Phone number
6 WELL DETAILS a TOTAL DEPTH 4J`/
-5
PS OTopographic map
on a USGS topo map andattached to
/,6
g
State Zip Code
b DOES WELL REPLACE EXISTING WELL/ YES 0 NO
c WATER LEVEL Below Top of Casing -) Lf FT
(Use °+' if Above Top of Casing)
d TOP OF CASING IS I FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 1 METHOD OF TEST p
f DISINFECTION Type
Amount tS
11 DRILLING LOG
Top Bottom Formation Descnption
/
/
/
/
12 REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
SIGNATURE OF CE IFIEWELL ONTRACTOR DATA S
'l l
PRINTED NAME OF PERSON CSNSTRUCTING THE WELFEB , 5 20 [3
Submit w thin 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone , [phone]
Form GW-la
Rev 2/09