382815_Well Construction - GW1_20100427

RESIDENTIAL WELL CONS 1 RUC rloN RECORD
North 6 arolina Dcpartmcnt of 1 nvironntcnt and Natural Kctioutcc,- DIN ititon of Watu Uwtlu,
WELI CON ►RACTORCI RIIIICvIIONh ,VC WC 2839-4
1 WELL CONTRACTOR
Brian Lillev
Well Contractor (Individual) Name
Aaua Drill Inc
Well Contractor Company Name
4137 Moores Mill Road
Street Address
Spencer
City or Town
( 336 _) 76-
Area cooe Phone number
2 WELL INFORMATION �I ,,��
NELL C OHS I RUCTION PERMITg-0308i0 r0
OTHER ,,SSOCIATED PERMIT#(1f applicable)
SITE WELL ID nnii appiicao1e)_
VA 24165
State Zip Code
3 WELL USE tCnec), Applicable Box) Residential Water Supply r�
AM in PMr'
F D:I_LED
Q-1 _do
TIME COtviPLETED I . Ob
4 WELCATION
CIT / �1J COUNTY _-
246' Grrrc,6 0-A-rec . Vt. octi
S,ree, Na,ne hampers L.ommuniN Suooivision Lot No Panel Zip Goee)
TOPOGRAP/HIC / LAND SETTING (check appropriate pox)
Slope EXalley ?Flat r)Ridge DOther
LATITUDE 36 DMS OR 3X XXXXXXXXX DD
LONGITUDE 75 DMS OR 7X XXXXXXXXX DD
Latitude/longitude source -GPS TjTopographlc map
(IOCatron of ,.ell must oe snows on a USGS ropo map andattached to
r,s ,orm 't no using GPS)
5 WELL OWNER
Ownt r �an1e
t
Sire, t ,oaresS
City or I own
red code Pnone numoei
6 WELL DETAILS
a TOTAL DEPTH
b
c
d
State Zip Code
DOES WELL REPLACE EXISTING WELL? YES 0
WATER LEVEL Below Top of Casing Sd
(Use - if Above Top of Casing)
TOP OF CASING IS _— FT Above Land Surface
Top or casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gprn) J E OD OF TEST
DISINFECTION Type Amount
NO 11/
FT
g WATER ZONES (depth)
Top / Op Bottom j jD
Top Bottom
Top Bottom
7 CASING Depth
Top 0 Bot,or111Z
Top Bottom
Top Bottom
8 GROUT Deptn ��
BottornFt CO ('r —
Top Bosom
Top Bottom
Top Bottom
Thickness/
pia eter Weight Material
Ft
Ft
Material Metnoc
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Top Bottom
Top Bottom
Top Bottom
10 SAND/GRAVEL PACK
Depth
Top Bottom__
Top Bottom_
Top Bottom__
Diameter Slot Size
Ft in --
Ft — Ft in
Ft
Ft
Ft
n
n
Material
Size Material
11 DRILLING LOG
Top Bottom Formation Description
___/ o
do / ‘F.k-
-/ /CD
La--/ 1/0 " =a te
/l D /J__----t`
12 REMARKS APR 2 9 � ¢
_ zoo
f tmfoi maiiu ,, ,_
w,g unit
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C WELL CONSTRUCTION
STA ! .'DS AND THAT A COPY OF THIS RECORD HAS BEEN
p• •VID' D TO THE WE OWNER
PRINTED NA'iF PERSON CONSTRUCTING THE WELL
Forst G`' 'a
Izev 2/06
Submit within 30 days of completion to Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Information Processing