389460_Well Construction - GW1_20101119

RESIDENTIAL WELL- CONSTRUCTIONRECORD
North Carolina Department of -Environment and Natural Resources- Division of Water Quality
WELL CONTRACTORCERTIFIC-ATION #-1VCWC 2839-A
1. WELL CONTRACTOR.
Brien Lilley
Weil Contractor (Individual) Name
qua Qnib: Inc
Weil Contractor Company Name
4137 MoQre$ Mi(I Road
Street Address
Spencer
City or Town-
- VA= - 24165
State Zap Code
( 336 -) 767;0747 -
Area code Phone number
2. WELL INFORMATION* - - ±y� '
WELL CONSTRUCTION PERMrr#4Ie U) / 20/047 - Di 1
OTHER ASSOCIATED PERMIT#(d applicable)
SITE-WELL,ID #(dapplicable) /
3 WELL USE-(CheckApplicable Box) Residential --Water Supply
DATE DRILLED •-11
TIME COMPLETED AM 0 PM 0
4. WELL LOCATI141.
CITY ► v)-r /y! gAi COUNTY
izte
(Street Name; Numbers, Community, Subdivision, Lot No , Parcel,Zp Code)
TOPOGRAPHIC / LAND SETT NG (check approphate box)
❑Slope ❑Valley I Flat t midge °Other - -
LATITUDE 36 "2 ' S 8 Z " DMS OR 3x.xxxxxxxxx DD_
LONGITUDE iI Sa '36 ' 2 b " DMS OR 7X XxxxxXXxx DD
Latitude/longitude source. 03PS ❑ropographic map -
(/ocation of well must be shown on a USGS topo map andattached to
this form if not using GPS) -
5 WEt�►AIVNER
L) SSt. ®PP
Owner Name
I`4%-
Street Address
City or Town
Area code Phone number
State Zip Code
6 WELL DETAILS. L,�
a TOTAL DEPTH: 0
b. DOES WELL REPLACE EXISTING WELL? = YES D NO t"
c WATER LEVEL Below Top of Casing` -. - FT
(Use "+" if Above Top of Casing}
d TOP OF CASING IS 1 - FT Above-I.2nd,Su'riace`
'Top of casing terminated at/or below land sutface may require
a variance in accordance with OA NCAC 2C 0118
e YIELD (gpm) I METHOD OF'r£ST,
f DISINFECTION: Type I t %- Amount 1 Z, O
=Submitinriiftrl�s3o day_s,=of.completIonyto; i3avision ofWater Quality:-
1 17 Mail $ervlce Center, -Raleigh; i C;27699-161, Phone [phone]
�3j,Fr�Fu'i
F.`
g: WATER ZONES (depth)
Top E)O - Bottom -'S1Y Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING. Depth Diameter
Top C) - Bottom Z.S FL- ZS -
Top Bottom Ft
Top Bottom FL
Thickness/
Weight terial
8 -GROUT Depth Material
Top G7 - Bottom 2 Ft I i.Ti$x DFTT
Top Bottom Ft
Top _ Bottom Ft
Method
9. SCREEN. Depth Diameter Slot Size Material
Top Bottom FL in m
Top Bottom Ft in in
Top Bottom Ft In in
10. SAND/GRAVEL PACK.
Depth Size Material
Top Bottom Ft
Top Bottom Ft.
Top Bottom Ft
11 DRILLING LOG
Top Bottom
p l /0
/b / 2-
"t.S /5
5 I S�S
/ oS
/
12 REMARKS
Foo nnation Description
%:C j
w
'LEEt-
I DO HEREBY -CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STAND L ' DS; ANDFJA'r tCOPY OF THIS RECORD HAS BEEN
P' % r ID a TO TH SELL WNER
/0- Z4-io
SI a .t RE OF CELL CONTRACTOR DATE
'Bnan 'Alley, - __
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
Rev 2/09