381915_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 CON�TRACTOR
Wet Contractor (indmdual) Name C
JL'd � � c,i1(s r`12.� f 5 6}7t.
Well Contractors Co�mpany,Nrame
(Street Address /
/G(%t./';
City or Tdwn d
L) 445-- 02.0
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
ed7J
State Zip Code
.101) i-CD) -
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED io2-.2 - ( `
TIME COMPLETED ____-7; 30 AM 0 PM I2
4 WELL LOCATION
CITY (k ' Cc,,, f'-U' 11 i coUINTY ? u. i, e o b
I Cd0 Cc-rv1_G 1 I,' ki)e/u;v'_c,0e A.
(Street Name Numbers, Corhmunity, Subdivision, Lot No , Parcel Zili Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley �Etat ❑Ridge ID Other
LATITUDE 36 °37 ' tecj� 141" DMS OR 3x XXXXXXXXX DD
LONGITUDE 75 ° 7 ' S t a5a " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source
(location of well must be sho
this form if not using GPS)
5 WELL OWNER
Owner Name
Streee Address
l'te(L (L)
d Toed
PS OTopographic map
on a USGS topo map andattached to
5 11e Rio G.
City or Town State Zip Code
LY , — y SS/
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL' YES 0
c WATER LEVEL Below Top of Casing 36
(Use °+" if Above Top of Casing)
d TOP OF CASING IS f FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 011
e YIELD (gpm) _30 METHOD OF TEST
f DISINFECTION Type Amount oLr
NO tlt`�
FT
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7 CASING
Top
Top
Top
Depth / / Diameter
Bottom / t'"Ft � q
Bottom Ft
Bottom Ft
Thickness/
Weight atenal
8 GROUT Depth Matenal Method
Top 0 Bottom ao Ft taem ei t
Top Bottom Ft
Top Bottom Ft
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 Matenal
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
To� / Bottom (
/
/
/
/
/
12 REMARKS
Formation Descnption
crack
Acid. fitr,_
R
°
en `° t n'1(\
vioc'oo
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 1/1/�LL OWNER
n n
SIGNATURE OF CERTIFIEDf
ei►aic.k k
PR TED NAME OF PERSON C
WELL CONTRACTOR DATE
n �1' I-
NSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mai( Service Center, Raleigh, NC 27699-161, Phone [phone]
T m g,
coeI rm 2/09 GW-1a
FEB 2 5 2013