382609_Well Construction - GW1_20100420

RESIDENTIAL WELL CONS I RUC I ION RECORD
North L arohna l)Lpartment of Lnvtronntr,nt and Natural Rusourcu,- I)Iv'slur) pi WatLI Quality
WI I LCONTRACrORCLRTITICkIION 0 `\CWC2839-4
3
()2 9ei
g WATER ZONES (depth)
1 WELL CONTRACTOR ToP GQ+v� Bottom d/d fop
Brian Lillev Top Bottom Top
Well Contractor (Individual) Name Top
Aaua Drill Inc Top Bottom
Well Comrac or Company Name
4137 Moores Mill Road
Street Address
SDencer VA 24165
State Zip Code
City or
336 _) 767-0747
-,rea cone Phone number
2 WELL INFORMATION
'NELL COr'SIRUC IION �ERMITu
OTHER ASSOCIATED PERMIT#(d applicaole)
SITE WELL ID #to, applicaole)
3 WELL USE '..neck Applicable Box) Residential Water Supply l�
i IME COMHLETtb_
AM ,2 PM
4 WEL ATION
ir
c, - �.,lo rL)x1 COUNTY T_ —
�
S,ree, n- NUtnJeia Cp,iltnu, ui) SuDowflslon Lot No at Ctl 7ip 8 WC)
TOPOGRAPHIC / LAN p SETTING (cneck appropriate pox)
-, Slope C Valley 1, lat 0 Ridge ❑ Other
' DMS OR 3X3X XXXXXXXXX DD
LATITUDE 6
LONGITUDE 15
Latitudellong'tude source _CPS LjTopograpnic map
notation of .eu n,us' DC sno/vn on a USGS topo map andattacned to
n,s rt,rm ,t no using GPS)
5 WELL OWNS
Ownr , Name
Strer,-.odieSS
City of (own
DMS OR 7X XXXXXXXXX DD
State Zip Code
Area code Pnone nurnber
6 WELL DETAILS
a TOTAL DEPTH di06— _
t, DOES WELL REPLACE EXISTING WELL? YES a NO L_
FT
c WATER LEVEL Below
Top of Casing
(Use
f Casing)
d TOP OF CASING IS FT FT Above Land Surface
Fop or casing terminated at/or below lane surface may require
a variance to a ajc,cordance with 15A NCAC 2C 0118
e YIELD (gprn) T� - MEOD OF TEST Qom,
Amount G d� —_
f DISINFECTION Type
Submit withService0 clays
of completion
tiC 27to Division Phooe f Water Quality6Information Processing
1617 Mail
7 CASING Depth Diameter
Diameter
6
Top O Bottom i Ft Le
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth /? Material
0 Ft l^ff�r
Top 0 Bottom
Top Bottom Ft
Top Bottom Ft
Bottom
Bottom
Bottom
Thickness)
�W�eiighht Material
.A:1
M e t n od
9 SCREEN Depth Diameter Slot Size
Top Bottom Ft n ,,,
Top
Bottom Ft in III
Top_ Bottom
Ft in 'r
Material
10 SAND/GRAVEL PACK Material
Depth Size
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
p i/
/a l sjo
34' I3
3s 140
4d ' 56a
'58c / S 0
,10
12 REMARKS
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC 1 ED IN
ACCORDANCE WITH 15A NCAC 2C WELL CONSTRUCTION
STA • RDS AND THAT A COPY OF THIS RECORD HAS BEEN
P^ • r D TO THE ELL OWNER
Brian Lille
PRINTED NA 'F PERSON CONSTRUCTING THE WELL
4->Z iv
IED WELL CONTRACTOR DYTE
Form G`A' to
--?e. 'IGJ_