384421_Well Construction - GW1_20100610

RESIDENTIAL WELL CONSTRUCTION RECORD
No i Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
I Ls
Well Contractor (Individual) Name
►MX()i S 1.1e1 I�rii�l'�I
Well Contractor CompaN Name
,. 1Co+4((I id.
Street Address
CA1I, r.6*• c_ NC_, 017 On
City or Town State Zip Code
Area code Phone number
2 WELL INFORMATION: WELL CONSTRUCTION PERMIT# C�-s ) ,3 Q v
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #{ef applicable)
3. WELL USE (Check Applicable Box) Residential Water Supply Q
Zr1 50-fi�fl
DATE DRILLED 3— 5— 1 V
TIME COMPLETED '- Oct AM ❑ PM [ ^
4. WELL
OCATION:
CITY w e Sl�l ✓���1 COUNTY
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING- (check appropnate box)
❑Slope ❑Valley ❑Flat ipl<ge ❑Other
LATITUDE 36 IR' 1,99(60 DMS OR 3X.X)0xx xxxxx DD
LONGITUDE 75 "O' +D. XO' DMS OR 7x xxxxxxxxx DD
Latitude/longitude source fS Qfopographec map
(location of well must be shown on a USGS topo map andattached to
this fonn if not using GPS)
5. WELL OWNER
Sv e- er1 5r,f(
Owner Name
SAddress
re t
N)ULI
2&3s
City or Town State Zip Code
(11) (r�-11c/
Area code Phone number
6. WELL DETAILS: �/,
a. TOTAL DEPTH: V
b. DOES WELL REPLACE EXISTING WELL? YES ❑ Nt
c. WATER LEVEL Below Top of Casing FT
(Use "+" 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)- 0 METHOD OF TEST Cvr
f. DISINFECTION: Type ) - TI4 Amount \
g. WATER ZONES (de th)
Top 0 Bottom(_ Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top 0 Bottom t-I 1 Ft 6 e'`)
Top Bottom Ft
Top Bottom Ft
8. GROUT Depth
Top (') Bottom Q 0
Top Bottom
Top Bottom
Bottom
Bottom
Bottom
Thickness/
Weight MaArjiL
gg
Material
Ftte f-) \131 i k_
Ft
Ft
Method
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft in. in
Top Bottom Ft in. in.
Top Bottom Ft in. in
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
© / I O'
90 /35 '
/L►O'
Li o / LI'l`
L1 / 9 00'
/
/
Size Material
Formation Descnption
rS
131 vb 1-1; -1-e_
(;-v c r V1 N !
/ JUN 1 0 Z01U
/
Information Nrocz-:sseng Unit
12 REMARKS DWQ/BOG
I DO 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
3-/6-1b
NATURE OF CERTIFIED WELL CONTRACTOR DATE
��� ►r1 CI-1 L.JJ
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•