384044_Well Construction - GW1_20100528

RESIDENTIAL WELL CONSTRUCTION RECORD
North CaroLna Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR /
./1L c ke arc ed
vveli Contractor (Individuai) Name
t-s2.5 .t ,.3 c7t
Well contractor Company Name
Street Address f '3
./ i AJ2��r; /i if �i $7
Crty or T dwn c/ State Zip Code
.E) /246- Q20--
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# �(
OTHER ASSOCIATED PERMIT#(d applicable)
SiTE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED
TIME COMPLETED `C i E'` AM 0 PM
a WELL LOCATION ----)
e
CITY F.L i 1:0/ , t i/L.j COUNTY b li'r;t,.,:'!'-b-C._.
(Street Name Numbers Community, Subdrnsion LotiNo , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (cried( appropnate box)
dope ❑Valley ❑Flat ['Ridge ❑Other
LATITUDE 36 ° r 'telifY-21/9l3y.S OR 3x XXXXXXXXX DD
°''.01-'' `it' 'r .JDMS OR 7x XXXXXXXXX DO
LONGITUDE 75
Latitude/longitude source PS DTopographic map
(locatbon of welt must be sho on a USGS topo map andattached to
this form rf not using GPS)
5 WELL OWNER.—
-
/f % lt`/, '< -(cif
Owner Name "-'
.��// /)lx` /
City or l own
( ) / 7 l(-'! •) (-,
Area code Phone number
Street tic71 ss
G WELL DETAILS
a TOTAL DEPTH
i/
b DOES WELL REPLACE EXISTING WELL') YES ❑
%- /? ,�('.% `L '7
State Zip Code
NO
f j)
c WATER LEVEL Below Top of Casing 4 (/ FT
(Use °+" if Above Top of Casing)
d TOP OF CASING IS 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
f DISINFECTION Type �) i i�� _ Amount
METHOD OF TEST /
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
Top Bottom Top
7 CASING Depth Diameter
Top / Bottom /f } Ft te fil
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom IO Ft
Top Bottom
Top Bottom
Ft
Ft
Bottom
Bottom
Bottom
3� 4044
Thickness/
Weight aterial
Material
t'_emell#
Method
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in
Top Bottom Ft in
Top Bottom Ft in
in
in
m
10 SAND/GRAVEL PACK
Depth Size Matenal
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
To Bottom
/ / Ge
Formation Descnption
r +
j
MAY 2 8 z010
„�wr;u�,aon f'roC"ss,rig Unit
12 REMARKS DWQ/SOL;
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
5-6- 0
SIGNATURE OF CEFiTIFIEIdWELL ONTRACTOR DATE
PR TED NAME OF PERSON C NSTRUCTING THE WELL
kfi
Submit within; 30 days of completion to- Division of Water Quality - information Processing
617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-1a
Rev 2/09
JA 162010