388646_Well Construction - GW1_20101102

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
� e /V, Churl
Weil Contractor (IndhAduel) Name
m 4til ( T.5.
Well Contractor Company Name
STREET ADDRESS lD 7a t� f-�z, ksbb•
rlt,\kZ iJ c- Y,,tIco
City or Town State Zip Code
(714)- 3 5g - / 50
Area code- Phone number
2) WELL INFORMATION:
SITE WELL ID *(if applicable
STATE WELL PERMIT#(dapplicable)
)
�r
h
DWQ or OTHER PERMIT Cif applicable) /.9 e t_I
WELL USE (Check Applicable Box): Residential Water Supply D
DATE DRILLED /t _1 w' /0
TIME COMPLETED 2s. 3 O AM ❑ PA
3. WELL LOCATION:
CITY: C.- trw -►r- t COUNTY Al C k
/d 5-ZLp ("rece, ) g)7r
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
COSlope ❑Valley ❑Flat ❑Ridge ❑Other
(check appate box)
LATITUDE _a_5. 01 • 7v`J
LONGITUDE 1. / ° 01. 3
May be in degrees,
minutes, seconds or
in a decimal fonnat
Latitude/longitude source: isktTS DTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER,
OWNER'S NAME r) l k49
STREET ADDRESS /u5—.2.6 Grce,n {('Crot, G-Fj
City or Town State Zip Code
( 7e4 )- 9/i — /343
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: Li 0 t r
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NC'
c. WATER LEVEL Below Top of Casing: 1,21 FT.
(Use "F" if Above Top of Casing)
d. TOP OF CASING 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): i9 ') METHOD OF TEST 19l d-J
f. DISINFECTION: Type MTh"
g. WATER ZONES (depth): ds t
From P /S To 2 I 6.6From To
From 5 5' To .tee -Iagam To
From To From To
6. CASING:
Amount 2 !2 -
Thickness/
Depth Diameter Weight Aleterial
From ® To 1 , Ft. (9 VS/ $Dli. 1 oa f
From To FL
From To_ _ _— Ft.___
7. GROUT: Depth Material
From 0 ,To P-,)-. Ft. 'Jr
From To Ft`
From To Ft,
8. SCREEND pth Diameter Slot Size Material
From� / o Ft. In. In.
From To Ft In. In.
From To Ft. In. , in
9. SAND/GRAVEL PACK:
Depth Size ' Material
From To Ft.
Fr ] To Ft.
From To Ft.
10. DRILLING LOG
From To
-
/Ot
1I. REMARKS:
Formation D scriptkln
Ir1 o'-p P w a
,, i, I" , r -
NCUV U 2 LULU
information i-oc ssing brill
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100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WEIL CONSTRUCTION STANDARDS, AND 'MAT A COPY OF THIS
RECORDIIASBEEN PROVIDED TOTHE WELL 0 R.
/Y
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
E. INA( I; t.
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW1a
Rev. 7/05