387280_Well Construction - GW1_20100909

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2455
1 WELL CONTRACTOR
James D Harrinaton
Well Contractor (Individual) Name
Dale Todd Well Drillina
Well Contractor Company Name
711 Wellinaton Ave
Street Address
Wilminaton NC 28401
City or Town State Zip Code
( 910 ) 763-1261
g WATER ZONES (depth)
Top 88 Bottom 98 Top
Top Bottom Top
Top Bottom Top
7 CASING Depth Diameter
Top +2 Bottom 88 Ft 4"
Top Bottom Ft
Top Bottom Ft
Area code Phone number 8 GROUT Depth Matenal
2 WELL INFORMATION Top 0 Bottom 20 Ft bentonite
WELL CONSTRUCTION PERMIT# Top Bottom Ft
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(it applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 08/12/10
TIME COMPLETED 4 00 AM ❑ PM El
4 WELL LOCATION
CITY Wallace COUNTY DUDIIn
152 E Windina Wav Wallace NC 28466
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑ Valley VFlat ❑ Ridge ❑ Other
LATITUDE 36
LONGITUDE 75
Top Bottom Ft
9 SCREEN Depth
Top Bottom
Top Bottom
Top Bottom
10 SAND/GRAVEL PACK
Depth
Top Bottom
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
" DMS OR 3X XXXXXXXXX DD 0 /15
" DMS OR 7x XXXXXXXXX DD
Latitude/longitude source [GPS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
Tom Beer
Owner Name
15 /78
78 /98
/
152 E Windina Wav /
Street Address
Wallace NC 28446 /
City or Town State Zip Code
(703 ) 609-5239 /
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 98'
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO pI
c WATER LEVEL Below Top of Casing 32 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 2 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) 40aom METHOD OF TEST A/L
f DISINFECTION Type HTH Amount
12 REMARKS
41
, '
Bottom
Bottom
Bottom
80
Thickness/
Weight Material
sch 40 PVC
Method
pumped
Diameter Slot Size Material
Ft
Ft
Ft
Ft
Ft
Ft
in in
in in
in in
Size Material
Formation Descnption
grey F/S & roots
blue mud
grey F/S rock layers
RE( i ED
SEP dD 2010
Information
Unit
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
c/ / / / o
NATURE OF CERTIFIED WELL CO RACTOR DATE
James D on
PRINTED NAME IOFtPERSON CONSTRUCTING LL
Submit within 30 days of completion to Division of Water Quality - Information Processing,
OCT 14201
orm GW-la
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone] Rev 2/09