382791_Well Construction - GW1_20100426

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nat rat Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # C^ ? 3
1 WELL CONTRACTOR.
1-I czC ( Lti, S�
Well Contractor (Individual) Name
LC1),SC Lt) 1( Dr)1 / /1
Well Contractor Company Name
STREETADDRESS5 O / /3 5
t' 1 , oIhV1, e. . O'.,
City or Town State Zip Code
( `J / 9)- G: a - c) sty,
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
WELL CONSTRUCTION PERMIT# 9 7 au GC%
OTHER ASSOCIATED PERMIT#(d applicable)
3. WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED lF - 0 / t7
TIME COMPLETED* - / S- - 'DAM O M O
4. WELL LOCATION; //��
CITY f r1 h- COUNTY IC./� Lys
( treet Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAyB'BETTING
o Slope 0 Valley lat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 3.5 09 • 7! 5 rI
LONGITUDE Z1 O a _
Latitude/longitude source' PS o Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. WELL OWNER
OWNER'S NAME Q
STREET ADDRESS a
May be in degrees,
minutes, seconds or
in a decimal format
FAS 1.10>N i NG s 7V/
City or Town State Zip Code
( )-
Area code • Phone number
6 WELL DETAILS: ��
a TOTAL DEPTH
b. DOES WELL REPLACE EXISTING WELL? YES O NOp�
c WATER LEVEL. Below Top of Casing .f 0 FT
(Use '+' If Above Top of Casing)
d. TOP OF CASING IS 1 FT Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118,
e. YIELD (gpm) 1 0 METHOD OF TEST /'Q t • i
3': 2 7 91
f. DISINFECTION. Type /VT j Amount .3 Ir.14,'s
g. WATER ZONES (depth) VVVV
From (7 b To e7 5— From To
From To From To
From To From To
7. CASING' Thickness/
DepthToDiameter Weigh;Vat ar
From b To 6 S Ft it
L
From To Ft
From To Ft
8. GROUT: Depth Materiall Method
From 0To �O Ft____�
%0/Gi'Y�
___
From To Ft
From To Ft
9. SCREEN* Depth Ay Diameter Slot Size ,al
From 4, g To "/ 5 ptgr
Ft 1 in / j` in VC. -
From To Ft In in
From To Ft in In
10, SAND/GRAVEL PACK.
Depth Size Malarial
From t1,14To )' 5 Ft / ry0 ✓j , •�;�� /
/ From 're,) To 1> S Ft / Q 0 0 - / -
..„.
From To Ft
11, DRILLING LOG
From To Formation Descnption
/
b
ls,
�
1 ' - a .., "�,�nnQ
k-
h 0 7 S' Q..tv.,- Z=3-1-,0C-
RED
12 REMARKS: APR 2010
2
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Information 1'rouest-An°
mica/BON
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
1SA NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT ACOPY OF THIS
RECOR HAS BEEN PROVIDED TO THE WELL OWNER
k-rt: (l' 4.:1E) -1 y- C2r
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
/'fcI(.LCe LL)1.�e
P 1NTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568
Form GW-la
Rev 3/07
FEB 1 ' 2014