386556_Well Construction - GW1_20100901

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RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3 /
1. WELL CONTRACTOR:
C_t,e,c N 'ct,.as
Wel Contractor (Individual) Name
✓�`Cc Cj BrcS.
Well Contractor Company Name
STREET ADDRESS ..Fr'oo k5hr / e 'Ffodg •
Chart k N•(• 2i-270
(7o`/)- 3T•9'-(50c:
City or Town State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applcabte)
STATE WELL PERMIT#(rf applicable)
DWQ or OTHER PERMIT Cif applicable) /000 4 y
WELL USE (Check Applicable Box): Residential Water SupplyK
DATE DRILLED "
TIME COMPLETED /2 : U (D AM 0 PM
reC
3. WELL LOCATION:
CITY: / o -ITS COUNTY /4 C K •
3360 zdtk.S;,fe66. a?o
(Street Name, Numbers, Community, SubdMalon, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ()Ridge ❑Other
(check appropriate box)
LATITUDE ..a. , . ). /-2 5-6
LONGITUDE D ° Li 5 . 7 7 (.3
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: , PS °Topographic map
(location of wellmust be shown on a USGS topo map and
attached to this form Ifnot using GPS)
4. WELL OWNER
OWNER'S NAME
Dav 0 err';et\ B0.GV.
STREET ADDRESS 3360 bike Saler.
d
_(, % r/ o 4( e- A/. C. 62 7 V
City or Town State Zip Code
( 70Li, )- f6 `l- /&95
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES(YESkr NO ❑
e. WATER LEVEL Below Top of Casing: 3 C) FT.
(Use'+' if Above Top of Casing)
d. TOP OF CASING 18 / • 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 Wpm): • METHOD OF TEST Tla t.✓
3L 6556
f. DISINFECTION: Type 'TH Amount 1 0�
g. WATER ZONES (depth :, $ yy,
From 1' 3 To (I From To
From To From To
From _To From To
8. CASING: Thickness/
Depth Diameter Weight
From 0 To `)(n Ft. 6 WV fp1a/oo
From To FL
From To ----__ Ft._
Material
PVC,
7. GROUT: Depth Material Method
From © To .24 Ft%3ent:,n,i!>`.Ps S(Aigat.rx✓ 'y�
From To Ft,
From To Ft
8. SCREEN.
epth Diameter Slot Size Material
From To Ft. In. In.
From To Ft In. In.
From To Ft. In. in
9. SAND/GRAVEL PACK:
De
Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
— 90
/f3'l6'1r
(ce -3ao
Formation Des r�rIiption
Verb c4faeet—
Bee/ ✓A) Lots csfTa61 n.tre.Q
731he G��•,+�
nrn v
.J L.I A
')non
LV ILO
Info„ . r , t JDII ly vrrn
11. REMARKS:
2/D«/ / s ' - / qg
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
G ILe-wr/ t N i (Loll
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] eat 668.
Form OW -la
Rev. 7/05