387414_Well Construction - GW1_20100914

e YIELD (gpm)
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 2839-A
1 WELL CONTRACTOR
Brian Lilley
Well Contractor (Individual) Name
Aqua Drill. Inc
Well Contractor Company Name
4137 Moores Mill Road
Street Address
Spencer VA 24165
City or Town State Zip Code
( 336) 767-0747
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 1_t480IO- 03
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) rderiiti
( Qom/ ,
3 WELL USE (Check Applicable Box) ft"Watef Supply ❑
DATE DRILLED 4 ''lG
TIME COMPLETED AM ❑ PM ❑
4 WELL LOCATION
CITY 1-1 COUNTY
77 9 CvtpEE'i lit. - 27o 30
(Street Name Numbers Community, Subdivision Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETT G (check appropnate box)
❑ Slope ❑ Valley ❑ Flat Ridge ❑ Other
LATITUDE 36 "DMS OR 3x Xxxxxxxxx DD
LONGITUDE 75 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source [(GPS [(Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
1vt,Lr C1z.
Owner Name
Street Address y-
City or Town
Areacode Phone number
6 WELL DETAILS
TOTAL DEPTH Sos-
a
b
DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing So
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 011811
METHOD OF TEST 16 ?4)
State
Zip Code
YES NOCT
FT
f DISINFECTION Type � Amount
374
g WATER ZONES (depth)
Top /40 Bottom t4•6 Top Bottom
Top 7 ;5O Bottoms Top Bottom
Top Bottom Top Bottom
7 CASING Depth //
Top 0Bottom b,'
Top Bottom
Top Bottom
Thickness/
Diameter --�Wyeight Material
Ft SW-2> ft c
Ft
Ft
8 GROUT Depth /LM"atenal
Top Ci Bottom 70 Ft C.Er✓Ici. is
Top Bottom Ft
Top Bottom Ft
4 Method
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
6 / /o
Size Material
Fo ation Descnption
10 /,4$
4� 1466 c„,1
("4 I E;(
140 l QS•
/k 1254
Zs-6 /
12 REMARKS
Z
cit i +. r.:C
)
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bg 1 ()co.
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORD E WITH 15A NCAC 2C, WELL CONSTRUCTION
STAN ra ' D'-, AND THAT OPY OF THIS RECORD HAS BEEN
PR • •IDE• OTHE WE 0\ NER
Sle NATUR. OF C
Bria ley
LL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to. Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-la
Rev 2/09