381920_Well Construction - GW1_20100323

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Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 22).
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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION #
1 WELL CO TRACTOR
Well Contractor (Individual) Name
Well contractor Company Nrame
Street Address
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City orTdwn d
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Area code Phone number
2 WELL INFORMATION.
WELL CONSTRUCTION PERMIT#
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Top
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth ,, JDiameter Weight
,�179 Top / Bottom / Ft 0 4 at l
L Top Bottom Ft
State Zip Code
Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED /— i Oa)
TIME COMPLETED � 3v AM 0 PN
4 WELL LOCATION
CITY J iv a nilco1C6--
COUNTY
(Street Name Numbers, Community, Subdivision, Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope- Valley CFiat ORidge ❑Other
LATITUDE 36 '3S ' 5113Yt/ "DMS OR 3X XXXXXXXXX DD
LONGITUDE 75 ' g,, • Id " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source PS ['Topographic map
(location of well must be sho on a USGS topo map andattached to
this form rf not using GPS)
5 WELL OWI ER IJ( E
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Owner Name
Street Address
IA/ Cc/1�1 <'iv. G ��
City or Town State Zip Code
b DOES WELL REPLACE EXISTING WELL' YES 0 NO
c
WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
d TOP OF CASING IS
e
f DISINFECTION Type
1
y` 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) 3 METHOD OF TEST
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Amount PRATED NAME OF PERSON C NSTRUC ThiE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, F]
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone] �01� Form GW-la
FEB Rev 2/09
8 GROUT Depth
Top 0 Bottom O Ft
Top Bottom Ft
Top Bottom Ft
Material
t
WATER ZONES (depth)
Bottom Top Bottom
ateria I
Method
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9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in m
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top
Bottom{ Formation Descnption
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12 REMARKS
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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 ELL OWNER
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SIGNATURE OF CE IFIEe WELL ONTRACTOR DATE
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