383888_Well Construction - GW1_20100526

RESIDENTIAL WELL CONSTRICTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality s-
WELL CONTRACTOR CERTIFICATION # ) J-1 5
1. WELL ONTRACTO
ak) i d)1 VI 1"0 I2 S
WeA C actor (1 uaQ Nome
Well Contractor Company Name pp�� �/ I_
STREET DDRES �� l) > (5 I!`�V\_.i VQ
City or Town State
-(76k). )OSQ - 6 (
Area code- Phone number
Zip Code
2. WELL INFORMATION:
SITE WELL ID #(If applicable) 1
STATE WELL PERMIT#(d applicable) 1 Op c L( 3
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box): Residential Water Supply p
DATE DRILLED — o� S
TIME COMPLETED
AM ❑ PM CI
3. WELL LOCAAT�ON:
CITY: l�W 16 \ COUNTY l k(C/k„e)
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
❑Slope ❑Valley J4Flat °Ridge ❑Other
(check appropriate box)
LATITUDE .._ S• s..�'
LONGITUDE U 5 a
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: jGPS oTapographic map
(location of weltmustt be shown on a USGS topo map and
attached to this form lfnot using GPS)
4. WELL OWNER r /
OWNER'S NAME I M O rct V e� Gt(".C.Q
STREET ADD E S 71 oL-�-� rra, kjja,CQ !e)
e �(
ty or Town S = Zip Code
L_LA
Area code • Phone number
5. WELL DETAILS:
l ` O
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
c. WATER LEVEL Below Top of Casing: 7 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASINO IS ( 1 / 2 FT. Above Land Surface"
`Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118 `
a. YIELD (gpm): '7 METHOD OF TEST t0 LA.)
f. DISINFECTION: Type 4 -I I-1- Amount 1 /7 (u
g. WATER ZONES (depth):
From To From To
Fr��,',',�)6 To a`3From To
Front , /7_To)!J/O f/ From To
6. CASING: Thickness/
From I if
o11LiOrtft. Deter Weigh',AApteriaai(
From To Ft. (D 5 I Q
From To Ft.__
7.GROUT: Depth Material
From 0 To ('-l02 Ft. C2M-A+
From To Ft,
From To Ft`
Method
h.� /-(1
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. In. In.
From To Ft In. In.
From To Ft. In. in
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
Sslr) - 13 0
( "Ca - )--(.1 6
11. REMARKS:
F mnatign Description
ea CI
q, 6 2(S1t)
rikiAt
;�‘ntmatoc,�IQI$�
IDOHERE
18A NCAC
RECORD
LL WAS CONSTRUCTEOIN ACCORDANCE WITH
STANDARDS. AND THAT A COPY OF THIS
THE WELL OWNER.
3as
SIG TUBE OF RT F1EC WELL CONTRACTOR DATE
au l (J) / rtpt
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality with n 30 days. Attn: information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-la
Rev. 7/05