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HomeMy WebLinkAbout382609_Well Construction - GW1_20100420RESIDENTIAL 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_