388140_Well Construction - GW1_20101007

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 f Ss-
1. WELL CONTRACTOR:
C kke
Welt Contractor (Individual) Name
`CJ/ 13r03.
Web Contractor Company Name
STREET ADDRESS LcT70c) 7J. kst,.n •`Y•
c. 8' 2( 6
City or Town State Zip Code
(70,( )- -3 4q- (S-a
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(inapplicable)
STATE WELL PERMIT#(rf applicable)
DWQ or OTHER PERMIT Cif applicable) /QDO `( ST3 .
WELL USE (Check Applicable Box): Residential Water Supply Q
DATE DRILLED
TIME COMPLETED a 0
3. WELL LOCATION:
CITY: 14+<ar-3t.;.)1�
(Street Name, Numbers, Community, Su
AM ❑ PME(
COUNTY
2O cr?
bdivisron, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley*Hat ❑Ridge pother
(check appropriate box)
LATITUDE _a_ 9 0 :)-C,�/• 1` 6 7
LONGITUDE Y QL �d i 03
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: PS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this fomt If not using GPS)
4. WELL OWNER
OWNER'S NAME 1-00*211- C 712-6r94h t••
STREET ADDRESS fP. d. 37C
141.4 t,. l 4 iV c. .7.1.470
City or Town State
( 7'1 )- 5r.2 38/4/
Area code - Phone number
8. WELL DETAILS: (goo(
a. TOTAL DEPTH: Cv
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO.(
c. WATER LEVEL Below Top of Casing: 3 Z FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASINO IS (• 5— 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): -� METHOD OF TEST 73./dhJ
f. DISINFECTION: Type HT,+ Amount 1,2- 4.6
g. WATER ZONES (depth):
From 2/5— Tom/j- 94.
From To
From 94/0 To `Iy0- I YFrom To
From To From To
8. CASING:
Depth Dlarneter
From 0 To rr/ Ft. 62 it5
From To FL
From ToFt.___
Thickness/
Material
arWeight Ste(
7. GROUT: Depth Material Method
From 0 To �8' Ft ge,dert.4tt4f 5-6c6.' o-r+-
From To Ft.
From To Ft,
8. SCREEN: Depth Diameter Stot Size Material
From SCREEN_ Depth
Ft. In. In.
From To Ft In. In.
From To Ft. In. in
9. SAND/GRAVEL PACK:
Dept t Size Material
From d74 To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
76,
74 -460
11. REMARKS:
Formation Description
d LUIU
mrormarion Pi-ocp,bing Unit
DV/C 13OG
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD tjA5 BEEN P.ROwt>@0 TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
l.z N;(c�ois
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water quality within 30 days. Attn: information MgL,
1617 Mail Service Center— Raleigh, NC 27899-1817 Phone No. [phone] ext 668.
Form GW-la
Rev. 7/05