387411_Well Construction - GW1_20100914

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
Bnan Utley
Well Contractor (Individual) Name
Aqua Drill. Inc
Well Contractor Company Name
4137 Moores Mill Road
Street Address
Spencer
City or Town
( 336) 767-0747
Area code Phone number
2 WELL INFORMATION tenn'' (�
WELL CONSTRUCTION PERMIT Yam(.) D53OJ�-G�
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check Applicable Box) Residential Water Supply (J✓
DATE DRILLED q'-7 - to
TIME COMPLETED 4:oc
VA 24165
State Zip Code
AM PM(2r
4 WE CATION
CITY 3' ! /V Jig C-CE COUNTY
SZv CJuE2 fL 77043
(Street Name Numbers, Community Subdivision Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAr SETTING (check appropnate box)
❑Slope ❑Valley ineFlat ❑Ridge ❑Other
LATITUDE 36 °l / ' & - "DMS OR 3x XXXXXXXXX DD
LONGITUDE NC!) ° Z7' 4o.q " DMS OR 7x Xxxxxxxxx DD
Latitude/longitude source D3PS DT'opographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELNER
Owner Name
Street Address
City or Town
( )
Area code Phone number
State Zip Code
6 WELL DETAILS y
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 3 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 vanance in accordance with 15A NCAC 2C 0111.U18) kJC,. e YIELD (gpm) 1 S' -7iTH OF TEST U
f DISINFECTION Type } i + Amount 7 -b Z
c
g WATER ZONES (depth)
Top / L4 Bottom /4Top Bottom
Top 2U Bottom ZOS.' Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter` Weight Material
Top a Bottom Ft , 5)ez4
Top Bottom Ft
Top Bottom Ft
8 GROUT
Top a
Top
Top
9 SCREEN
Top
Top
Top
Depth
Bottom Zd
Material
Ft L 1..( l
Bottom Ft
Bottom Ft
Method
Depth Diameter Slot Size Material
Bottom Ft in in
Bottom Ft in in
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
n / /5
/ /40
Formation Descnption
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d o // t o
J o /1.65 #ILL_
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ryas it
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12 REMARKS
, f sir-- tl•-ik
1-4
V.
SEP 1 4 1-U10
Informationor- rrn
UVV Ca
Urfa
Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
CE WITH 1 C 2C, WELL CONSTRUCTION
S, AND T T A COY OF THIS RECORD HAS BEEN
TO THE WELL OWN R
DATE
PRINTED NAME 0 CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - Information Processing,
1617 Mad Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-la
Rev 2/09