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HomeMy WebLinkAbout380196_Well Construction - GW1_2010010801/07/2010 15 58 FAX ill 001/004 RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # 2630-A 3 0 9Lf 1. WELL CONTRACTOR: g. WATER ZONES (depth) KENNNETH P. DEROCHE' Top 95 Bottom 119 Top Bottom Well Contractor (Individual) Name Top Bottom Top Bottom MEADOWS WELL DRILLING Top Botom Top Bottom Well Contractor Company Name Thickness/ 775 ASHTON LAKE RO, - 7. CASING: Depth diameter Weight Material Street Address : Top 0 Bottom 99 Ft 2 sch40 pvc BURGAW NC 28457 Top Bottom Ft tty or Town State Zip Code Top Bottom Ft. ( 910) 259-5623 Area code Phone number 2. WELL INFORMATION; WELL CONSTRUCTION PERMIT# 74 OTHER ASSOCIATED PERMff#('dappiccable) SITE WELL ID #(if applicable) 3. WELL USE (Check Applicable Box): Residential Water Supply ft DATE DRILLED 12/08/09 TIME COMPLETED 4:00 AM 0 PM e_ WELL LOCATION: CITY: Turkey couNTY Duplin 150 POPE WRAY RD, 28393 (Street Name. Numbers, Cosenum iy, Subdivision, Lot No„ Parcel. Zip Code) TOPOGRAPHIC / LAND SETTING' (chedc appropnete box) ❑ Slope ❑Valley 6/1Flat ❑Ridge 0 Other LATITUDE 35 ° 2 • 33 8300 " DMS OR 3X.AAAX OD LONGITUDE 78 " a • i7 4458 " OMS OR 7x_Kx.xxxxr{XX OD Latiludefongltudesource• FitPS fit opographicmap (location of well must be shown on a USGS topo map andattached to this form rf not using GPS) 6 WELL OWNER ARTHUR ELLIOT GARRIS Owner Name 150 POPE WRAY RD. Street Address TURKEY _ _ 1IC 28393 City or Town State Tip Code (910 ) 284-0959 Area code Phone number 6. WELL DETAILS: a TOTAL DEPTH: 1 19 b. DOES WELL REPLACE EXISTING WELL? YES gr NO 0 c. WATER LEVEL Below Top of Casing 10 FT (Use -+" if Above Top of Casing) d. TOP OF CASING IS 1.5+ 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)- 25 METHOD OF TEST PUMP f DISINFECTION: Type hth DQy/der Amount 2 OZ. Submit within 30 days of completion to: Division of Water Quality - 1617 Mall Service Center, Raleigh, NC 27699-161, Phone : (919) 807-6300 8 GROUT Depth Material Top 0 Bottom 3 Ft typell cem. Method pour Top 3 Bottom 25 FL well grout DF pressure Top Bottom Ft. 9. SCREEN: Depth Diameter Slot Sae Material Top 99 Bottom 119 Ft2 in .010 In sch40pvc Top Top Bottom _ Ft. on in Bottom Ft. in. cn. 10. SAND/GRAVEL PACK: Depth Sirs Material Top 95 Bottom 119 Ft. 2 sterile silica Top Bottom Ft Top Bottom Ft 11 DRILLING LOG Top Bottom 1 /10 Formation Descnption top soil & sand 10 / 25 mod. tan sand 25 _ /46 med. tan sand & shell 46 /90 gray soft day 90 /119 coar,$e graili arid_'r"ht.(tti colored san / / 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. 1�L>aU' d "- r 12/08/09 SI NATURE OF CERTI ED W0.L CONTRACTOR DATE KENNETH P. DEROCHE' 1 PRINTED NAME OF PERSON CONSTRUCTING THE WELL CCTGJ2 3 Information Processing, Form GW-la Rev 2/09