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HomeMy WebLinkAbout388641_Well Construction - GW1_20101102STREET ADDRESS 117 ON RESIDENTIAL WELL CONSTRUCTION RECORDS North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # 3 1.WE ONTRACT R: li d t 1-11'`'l a rLS Well Contract (Individual) N e Pi n l ( 13i7p ir s Well Contractor Company ame o -76)v(rZYN.)15.L.1.4 Cal (r)P /Le Zip Code City or Town State Area code- Phone number 2. WELL INFORMATION: SITE WELL ID #(d applicable) STATE WELL PERMITt#(if applicable) DWQ or OTHER PERMIT #(if applicable) WELL USE (Check Applicable Box) Monitoring 0 MuhicipaUPubtic 0 IndustnatICommercial 0 Agncultural 0 Recovery 0 Injection ❑ Irrigation° Other ❑ (list use) Fer-\0C'Y419 C.A.>2 DATE DRILLED (?— — l G TIME COMPLETED I illDPAD 3. WELL LOCATI� CITY a5PP 4, AM ❑PM Or COUNTY (Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING ❑Slope ❑Valley *Flat ❑Ridge 0 Other (check appropriate box) LATITUDE 3 LONGITUDE _ELl) May be in degrees, minutes, seconds or in a decimal format Latitude/longitude source: 'GPS ❑Topographic map (location of well must be shown on a USGS topo map and attached to this form if not using GPS) 4. FACILITY. Is the name of the business who FACILITY ID #(if applicable) NAME OF FACILITY thew ';_ocated fCt STREET ADDRrQ VCi DU A_J,i e ,L - City or Town n Statgr Zip Code CONTACT PERSON '1' Cu l O Y 1 lS�1i Cv56L'I�I MAIL ADD ES (MO S-C) L IV I t 9CJ City o T _60State Area code - Phone number 5. WELL DETAILS: a. TOTAL DEPTH:✓ Zip Code b. DOES WELL REPLACE EXISTING WELL,?/ YES 0 NQ�' c. WATER LEVEL Below Top of Casing: /07/ 9 FT. (Use "+- if Above Top of Casing) S ,r 1 d. TOP OF CASING IS /v/%4- FT. Above Land Surface* 'Top of casing terminated atlor below land surface may require a vanance in accordance with 15A NCAC 2C 0118. t e, YIELD (gpm): / v//A METHOD OF TEST 1l1 f. DISINFECTION: Type ///j/- Amount 2/%4 g. WATER ZON From (depth) From To From To From To From To From To 6. CASING: Thickness/ Depth Diameter Weight atenal From r,LO To ( Ft. l From To Ft. From To Ft 7. GROUT: /DDepth Matenal Method From /r/,r—t,o Ft From To Ft. From To Ft. I. SCREEN: Depth Diameter Slot Size Material From -5 To ate From To From To 9. SAND/GRAVEL PACK: Dep Size Material From A 1/ *1 Ft From To Ft. From To Ft. Ft in. In /IC/C Ft. In. In. Ft. in, 10. DRILLING LOG From To {7-- rU 11. REMARKS: F nation Descnption Qt) NU QU 2 LULU Intormat:on processing Unit LJVV ,UOvv IDO EBY CERTIFY THAT THIS 15A 20, WELL CQq?jJJSTRUM! Rt RD HAS BEEN PfimVIDED TO ELL WAS CONSTRUCTED IN ACCORDANCE WI1N STANDARDS, AND THAT A COPY OF THIS E WELL OWNER SIG URE OF CERTIFIED WELL CONTRACTOR DATE Otu tCJ 5r�v��S PR TED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt., 1617 Mali Service Center —Raleigh, NC 27699-1617 Phone No. (919) 733-7016 ext 668. Form GW-lb Rev. 7/05