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HomeMy WebLinkAbout382377_Well Construction - GW1_20100409STAr( J� 1 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 (919) 807-6300 Information Processing, Form GW-la Rev 2/09