382377_Well Construction - GW1_20100409

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1 WELL CONTRACTOR
Brian Lillev
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Lnvironmcnt and Natural Rcsourccs- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC2839-A
Well Contractor (Individual) Name
Aaua Drill Inc
Well Contractor Company Name
4137 Moores Mill Road
Street Address
SDencer VA 24165
City or Town State Zip Code
( 336) 767-0747
Area code Phone number
2 WELL INFORMATION
WELL CONo-, RUCTIviJ PERMIT# SA
Sol /1/0 -0
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) /
3 WELL USE (Check Applicable Box) Residential Water Supply
DATE DRILLED J `Z-6 - lb
TIME COMPLE (ED Z-- 3
AMC' PMrj/.
4 WELLCATION ��
CITY I" L T � c^ �"� COUNTY )F
o� ---rat.12J
(Street Name Numoers Community Subdivision Lot No Parcel Zip Code)
TOPOGRAP IC / LAND SETTING (check appropriate box)
❑ Slope Aalley ❑ Flat ❑ Ridge U Other
1/
LA-f ITUDE 36 4�� _� °/ / ,( " DMS OR 3x XXXXXXXXX DD
LONGITUDE 7�&) °3) ' '`f " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source Lj¢S Qfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELNER
1G► c..k.1
-
Om ie, Name
N1G
Street Address
City or Town
Area code Phone number
State Zip Code
6 WELL DETAILS �� S a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES 0 NO ❑�
c WATER LEVEL Below Top of Casing 4-0 FT
(Use -+" if Above Top of Casing)
d TOP OF CASING IS FT Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118 )
e YIELD (gpm) 2) METH OF TEST i eJLL(
f DISINFECTION Type Amount B oS
Ck '/ P
(, V g
g WATER ZONES (depth)
Top ) 0-0 Bottom / / 0 Top Bottom
Bottom Top Bottom
Top Bottom
Thickness/
Dr meter Weight Material
Ft g 2 (- iC.,
Ft
Ft
Top
Top Bottom
7 CASING Depth
Top O Bottorrf
Top Bottom
Top Bottom
8 GROUT
Top 0
Top
Top
9 SCREEN
Top
Top
Top
Depth ��Material
Bottom Ft 1. M g_j/lethod
Bottom Ft
Bottom Ft
Depth Diameter Slot Size Material
Bottom Ft in in
Bottom Ft in in
Bottom Ft in in
10 SAND/GRAVEL PACK
Depth
Top Bottom
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
CZ, / 5e)
-3(., /
36
/7ov
ibo / /to
/0 / /gam
12 REMARKS
Size Material
Ft
Ft
Ft
Formation Description
et6qt1
Arm 0 g 2010
tnforma
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCT ION
STA AND TH COPY OF THIS RECORD HAS BEEN
P' •VIDEO O THE LL trWNER
SI
Brian
LL CONTRACTOR DATE
PRINTED NAME 0 PE .ON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Information Processing,
Form GW-la
Rev 2/09