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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 •