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