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HomeMy WebLinkAbout387411_Well Construction - GW1_20100914RESIDENTIAL 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 / J5,. (� l?a CdE d o // t o J o /1.65 #ILL_ l < l ryas it ":„..1 7iS /2ZZ i1.ri a -AU rtr i-t�'L 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 (919) 807-6300 Form GW-la Rev 2/09