HomeMy WebLinkAbout382814_Well Construction - GW1_20100427RESIDENTIAL WELL CONS ► RUC FION RECORD
North Carolina Dcpartmcnt of 1 nvtronmcnt and Natwal I ourcc,- l)i Iron of A\ att.! Ouality
WELL CONTRAC1OI CI REII ICArION fl IVCWC 2839-,1
y �7WATER ZONES (oeptn)
1 WELL CONTRACTOR Top Z56 Bottom Top Bottom_
Brian UtleyToBottom Top Bottom
Well Contractor (Indryp ioual) Name Top Bottom
Top Bottom
Aaua Drill Inc Thickness/
Well Contractor Company Name
7 CASING Depth Diameter Weight Mr, aterra
41 Moores MIII Road lop 0 Bottom Ft 4 S a.-7,) !//,C---
Street Aodress VA 24165 Top Bottom
Ft
Spencer City or To\.n Top State Zip Code Bottom Ft
336_) 767-0747 Material Metnod
8 GROUT Depth�7 %�
Area code Phone number Bottom LGJ Ft �G�
Top
2 WELL INFORMATION Top Bo Orr
WELL CONS/RUCTION PERMITn - 27 -1
Top Bottom Ft
OTHER ASSOCIATED PERMIT#(f applicable)
SITE WELL ID »u aopi'capie,
3 WELL USE iCnecl. Applicable Box) Residential Water Supply 7(
L,.:-TE DRILLED
10
TIME COMPLETED _1
'011 AM PMi"/
4 WELL LQ�ATION
011 j ,t-0'r" I+11-J COUNTY �✓
Z9--
+S,rec, Ndine NuilJeiS l',OnlnlJ,lrl} SUpUIVlSiOn Lot NO Parcel Zip c,oael
TOPOGRAPHIC / LAND SETTING (check appropriate pox)
I)Slope❑Valley GFIat )Ridge ❑Other
L,,TITUDE 36 DMS OR 3X XX XXXXXXX DD
LONGITUDE 15 DMS OR 7X XXXXXXXXX DD
0autuoe/longitude source `_GPS Jropographic map
,Iocauor, or /veil must oe shown on a USGS tope map andartached to
ns form rr not using GPS)
5 WELL NER
Own(' iJdme
Street ^address
City or -town
',.ea Loae rldne hinder
b WELL DETAILS �+JJ
a TOTAL DEPTH 4 LS� /
b DOES WELL REPLACE EXISTING WELL? YES a NO iT✓
�``j FT
ow Top of
ing
(Use se
c WATERLEVEL+B flAbove Top ofsCasing)
(Use
d TOP OF CASING IS ___— FT Above Land Surtace
rop of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
7 YIELD (yprnl ETHOD OF TEST I tJt��(ri^'
e L-- j M
f DISINFECTION Type
}/ a Amount
f Water
ity -
SubrMailwithin
ServiceeCdays
enteroRalelycompletion
NC 27699- Division
SPhonoe (919) 07 61300 Information Processing
1617
State Zip Code
9 SCREEN Depth Diameter Slot Size Matenal
Top Bottom Ft in In
Bottom Ft in in
lop _ - -
op Bottom
Ft in n
10 SAND/GRAVEL PACK Material
Depth Size
Top Bottom Ft
Top Bottom Ft
Fop Boron, Ft
11 DRILLING LOG
Top Bottom
—
�/ Zso
7.50
/2—
La 41€
/
12 REMARKS
Formation Description
Informatr:in Pioczsstng iUn;r
- DWQ/BOta
I DO HEREBY CERTIFY THA1 1 HIS WELL VvAS CONS FRUCTED ih
ACCORDANCE WITH 15A NCAC 2C WELL CONSTRUCTION
STAND • RDS AND T • COPY OF THIS RECORD HAS BEEN
PRED TO TH i ELL.WNER
'- Zti0--io
ELL CONTRACTOR D TE
PRINTED NAME O ARSON CONSTRUCTING THE WELL
Form G`"'-1E
r,ev Z/US