382612_Well Construction - GW1_20100420

RESIDENTIAL WELL CONS FRUC Hors RECORD
North Laruhna Department of Lnvtronimnt and Natural Rc,owcc,- 1)Ivl Ion ul AValet Uualuv
‘VELL CONTRACTOR CLR►I► IC AI ION a~ NC WC 2839-r1
g WATER ZONES (aeptn)
1 WELL CONTRACTOR Top %� Bottum ) / - Top
Brian Llllev Top Bottom Top
Well Contractor (Individual) Name
Top Bottom Top
Aaua Drill Inc
Well Contractor Company Name
4137 Moores Mill Road
Street Aaoress
Spencer VA 24165
City or Town State Zip Code
( 336_) 767-0747
Area cone °hone number
2 INFORMATION °7 Zi D 1
'AELL EL- C CONSTRUCTION °ERMIT#
OTHER ASSOCIATED PERMIT#(il applicable)
SITE WELL ID #(it applicable,
3 WELL USE (Cnecn Applicable Box) Residential Water Supply
D `E DRILLED 44 J'I
IME COMPi_E1
4 WELL LOCATION
_
Rt l•lw
Bottom
Bonom
Bottom
AM PM _
COUNTY /f?�1l%'1211
S rest Nd,nc Nornbers CornLnunit' Subdivision Lot No Parcel Zip Code)
1 OPOGRAPHIC / LAID SETTING (check appropriate box)
Slope ID Valley ' lat ❑ Rlage ❑Other
LATITUDE 36 ' DMS OR 3x XXX DD
DMS OR 7x XXXXXXXXX DD
LONGITUDE 75
Latitude/longitude source _GPS [Topographic map
,locauon or ,e/t must oe snot:n on a USGS topo map andattacnea to
nis torn, ,r nor using GPS)
5 WEL- ER
A
Owner Name
My
Street -,eeress
City or Tow,,
Ao
State Zip Code
rea cone Pnone numoer
6 WELL DETAILS
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES NO
3 FT
(
c WATER LEVELBelow ifAboveTop ofsCasing)
(Usese'
d TOP OF CASING IS ___ FT Above Lana Surface
Top of casing terminated at/or below land surface may iegcire
a variance in accordance with 15A NCAC 2C 01'8
e {TEED (gprn) Z) METHOD OF TEST e.U_(d____—
f DISINFECTION Type
Submit withi30 days of completion
27to Division
of e Wa e) 0r Qu hty Information Processing
(9
1617 Mail Service
7 CASING Depth
//�� Diameter
Top © Bottor,g0 Ft
Bottom Ft
Top
Top Bottom Ft
8 GROUT
Too 0
Top
Top
Depth �7
Bottom LS
Bottoni
Bottom
Ft
Ft
Ft
Material
e✓
9 SCREEN Depth Diameter
Top BottomFt in
Top _ Bottom Ft in
lop Bottom_ Ft in
10 SAND/GRAVEL PACK
Depth
Bottom_
Top
Top
lop
Thickness)
Weight Material
Metnoc
Slot Size Material
in
n
Size Material
Ft _ ---
Bottom Ft
Bottom_ Ft _
11 DRILLING LOG
Top Bottom
0 / <e
/6 / D
�0 I70
12 REMARKS
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL Wr+S CONSTRUCTED Ir'
ACCORDANCE WITH 15A NCAC 2C WELL CONSTRUCTION
ST 'A' 'S AND TH COPY OF THIS RECORD nAS BEEN
P'OVIDE'1 TO THE LL OWNER
o
WELL CONTRACTOR DATE
F PERSON CONSTRUCTING THE WELL
Amount PRINTED NAME
Form 0,^ 1a
res. 2r09