384058_Well Construction - GW1_20100528

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CO TRACTOR- f l
,e e t1 fo
Well Contractor (Individual) Name
d S6.4;o(, e12.5 f 5
Welt contractor Company Name
/vas f/C /%, t2e99
Street Address
hit /0/9
City or Tdwn
Area code Phone number
2 WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
d$79J
State Zip Code
&Oil -(7C,13 '7
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED 5' 18 (0
TIME COMPLETED S co AM 0 PM [I'
4 WELL LOCATION
CITY LetCe�,}ec
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
Top Bottom Top
Bottom
Bottom
Bottom
Thickness/
7 CASING Depth Diameter Weight aterial
Top -} I Bottom (0 Ft iQ'V I /
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom a Ft t'� i e� t
Top Bottom Ft
Top Bottom Ft
Method
i�r)t a ed
9 SCREEN Depth Diameter Slot Sae Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
Size
COUNTY G v,rLCvrn Top Ft
( Mk-{e Roacl Og7Yg Top Bottom Ft
(Street Name Numbers, Community, Subdivision, Lot No , Parcel Zip Code)
Top Bottom Ft
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope 1jValiey ❑Flat oRidge ❑Other
LATITUDE 36
LONGITUDE 75
*3-5 ' hit i " DMS OR 3x xxxxxxxxx OD
* 02 ' 7/ O(a "DMS OR 7x XXXXXXXXX DO
Latitude/longitude source
(location of well must be sho
this form rf not using GPS)
5 WELL OWNER
CM H Hov - e S —La.(
Owner Name
(,095 (-i.t51•ev,11e. 1\t
Street Address
2ievici.er bc,nv, lie_
City or Town
(P2E) (0E4 L127LJ
Area code Phone number
G WELL DETAILS
a TOTAL DEPTH. 1 1c 5
PS :Topographic map
on a USGS topo map andattached to
lac 8 elf
State Zip Code
b DOES WELL REPLACE EXISTING WELL/ YES p
c WATER LEVEL Below Top of Casing u 0
(Use '+^ if Above Top of Casing)
d TOP OF CASING IS
NOx
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 (gpm)
f DISINFECTION Type
METHOD OF TEST
01. J
Amount 1S
10 SAND/GRAVEL PACK
Depth
Bottom
PR
11 DRILLING LOG
Top Bottom
(.' / (,0
6)0 / /(G
12 REMARKS
Matenal
Formation Descnption
ouee
_a<L!
v1AY ;� 2uiu
'Rho -lawn Ni Of._Sglri9 UPI?
V YYI.{/�3J�a
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
5-IS /c
SIGNATURE OF CE(11FIE14'WELL CONTRACTOR DATE
ekk; i; k
net,
TED NAME OF PERSON C' NSTRUCTING THE WELL
Submit within 30 days of completion to• Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Information Processing,
TMS
Form GW-la
Rev 2/09