384434_Well Construction - GW1_20100610

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qvalityt
WELL CONTRACTOR CERTIFICATION # nC % 3 I
1. WELD NTRACTOR:
\ Oh r-1 Cn k 110
Well Contractor (Individual),Nam
k k ce) 11 brkt.t i•i
Well Contractor CompanyName 5
Street Address
har-t o\ c, Gad �7
City or Town State Zip Code
5 5 5(6 9 Li
I/ 10--I
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#{dapplicable)
SITE WELL ID #(f appi°cable)
3. WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED S'- / - /O '.7-0,p," on
TIME COMPLETED' kJ- I Y / D AM 0 PM I
4. WELL LOCATION:
CITY: WCOUNTY L//11i G /'V
1: )1kt�( � Tvlr7\ L Rct
(Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropnate box)
❑Slope [Valley r XX
❑��Flat 4116
dge ❑Other
LATITUDE �3 7/ °DMS OR 3X.000O0x0x DD
LONGITUDE DO ° 7/ " DMS OR 7X.XX00X( DD
Latitude/longitude source: pp XXX
PS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WE OWNER
0o, V•VC\
er Name J
)a.01 S'�,1 I,°f. C, > Rd
't Address
� l�h e�s� 5 `J N Q a 9 / O(-I
City or Town State Zip Code
3a_ )^ 65Ce
Area code Phone number
6. WELL DETAILS: D
a. TOTAL DEPTH:
E35�,
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing.
(Use °+° if Above Top of Casing)
d. TOP OF CASING 1S / 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): METHOD OF TEST 4
4 FT.
f. DISINFECTION: Type /f TW Amount
g. WATER ZONES (depth):
Top iS Bottom ( 5.2 0 Top Bottom
Top Bottom 7/0 Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth v c� , Diameter Weight Material
Top 0 Bottom 0 Ft (D /2 i /)5 i'(2 C.
Top Bottom Ft
Top Bottom Ft
8. GROUT.����Depth i Material T- Method
Top C) Bottom 3 S iC7 Ft. e/UTO/li,�/ e gAiped
Top Bottom ° ° Ft.
Top Bottom Ft
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
Top
Top
Size
Bottom Ft
Bottom Ft
Bottom Ft
11. DRILLING LOG
Tog Bottom
0/ 26
/ (3Sr
/
/
/
12. REMARKS
mELC
• 12
F rmatin Des ?on
//
111"401U
I DO HEREBY CERTIFY THAT THIS)WELL WASICONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
ice, I").e:[:�% i , _/7- /
SIG URE OF CERTIFIED WELL CONTRACTOR DATE
07-6)14) ('2 /4 2ed/U iS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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