383884_Well Construction - GW1_20100526

C [i E- Prc 4241-cN
�r©5 4c
01 RESIDENTIAL WELL CONSTRUCTION RECORD . 0.
North Carolina Department of Environment and Natural Resources- Division of Water Quality 3 „ ` U `'t 8 4
WELL CONTRACTOR CERTIFICATION # 3 IC
1. WELL CONTRACTOR:
C kar l; s`c.kG (
Well Contractor (Individual) Name
/'b C(0.t,l Otis
Well Contractor Company Nemo
STREET ADDRESS 6y7OD -01-04/ev re - T -
Cl.tot r lo- i✓, ( a-k l (ro
City or Town State Zrp Code
( 701 )- 31.S - I Ce
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(If applicable)
STATE WELL PERMff#(dapplicable)
DWQ or OTHER PERMIT #(if applicable) /6003i8"5
WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED t -30-Or Mr I V V 14:1-.u.‘
TIME COMPLETED 1 -' AM 0 MAW
-
3. WELL LOCATION:
CITY: t� 11ew 10-k re /✓_ C - COUNTY !' CIZ
$? 7c) 5h 1- _ 5cL.. r f . Pr.2,2 e
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley Oat ID Ridge CI Other
(check appropriate bo
LATITUDE 01, 3a9
LONGITUDE q 1i 5 ,
Latitude/longitude source: OGPS oTopographic map
(location of weff must be shown on a USGS topo map and
attached to this tom Ina! using GPS)
4. WELL OWNER
OWNER'S NAME vLlc� prove J''Q e PTA ct c
STREET ADDRESS f-^�o 30 $taard•-+ VI °e..-cc/ A
C4aflotfe c.
City or Town a j ' State Zlp Code
(7C)'( ►- - ! 11
Area code . Phone number
May be in degrees,
minutes, seconds or
in a decimal format
8. WELL DETAILS: a. TOTAL DEPTH: l'l U 0 (
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO,1e
c. WATER LEVEL Below Top of Casing: Y d FT.
(Use "1" 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 variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): / 5-0 METHOD OF TEST W0
rN
f. DISINFECTION: Type 14-T t1' Amount I.5 I b S.
g. WATER ZONES (depth): / 5 C' �/r1
From 29 To ?� From To
From To From To
Frost To From To
8. CASING: Thickness/
Depth ,
From 0 To 'T Ft. g r eIer
From To FL
From To Ft.
Weight Material
z 6-0 ;(
7. GROUT: Depth Material Method
From a To .2-2--Ft.Y7tetG-a
From To Ft,
From To Ft�
B. SCREEN: Depth Diameter Skit Size Material
From To Ft. in. In.
From To Ft in. In.
From To Ft. in. In
9. SAND/GRAVEL PACK:
De Size Material
F To Ft.
From To Ft.
From To.... Ft.
10. DRILLING LOG
From To
0 — J-'
3Ce
3�- tl5D
11. REMARKS:
�a Formation y ption
re
?g" Sai if
G -may /2cxJC--
6 Z©1(J
1r0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
78A NCAC2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WEU INER.
SIGN TURE OF CERTIFIED WELL CONTRACTOR DATE
C koAr c rV ; salt s
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 27898-1817 Phone No. [phone] eat 588.
Form GW-la
Rev. 7/05