384435_Well Construction - GW1_20100610

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 6 C) s9
1. WELL C T CTOR:
r uMS
Well Contractor (Individual),Name
nrIL4 u3cti I ,
Well Contractor Compan Name
fie,C� � i1 Pei
eet Address
OS ©4- LIRCI 7
City or Town State Zip Code
Area code Phone number
2. WELL INFORMATION: /,
WELL CONSTRUCTION PERMIT# 0
9 - /3s
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box) Residential Water Supply ❑
DATE DRILLED 5 2 /— I 0 T5 JG
TIME COMPLETED tJ -0 t J 0 AM ❑ PMrip,
4. WELL LOCATION:�/T
CITY t (% edd i JL) / U 9U COUNTY 044'0 %l)
C(1.tc`-So_ S1 lD
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
:elope [Valley ❑ Flat ❑ Ridge
❑ Other
LATITUDE .410 (35 O. 4016 " DMS OR 3X.)00000X DD
LONGITUDE 0BO �/
" 7l' ,20 7 " DMS OR 7X.XXXXX00X DD
Latitude/longitude source Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Owner Name
a \- C c
St eet Address
City or Town
( ) -A
Area code Phone number
6. WELL DETAILS: />' `
a. TOTAL DEPTH: 5v V
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO V.
c. WATER LEVEL Below Top of Casing 6 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 ,J
e. YIELD (gpm) METHOD OF TEST /4'
f. DISINFECTION: Type frt./ ]1 Amount p
4�
9.
Top Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING; Depth p , Diameter Weight terial
Top 0Bottom c5D Ft 6/d 1/2-5
R &%. L
Top Bottom Ft
Top Bottom Ft
W TER,ZONES (de th),
Bottom 0
8. GROUT. Depth , Material Method
Top 6 Bottom 33 Ft. r`/f'N ' /04 if #01/r'7f0 ea'
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. SANDIGRAVEL PACK:
Depth
Top Bottom
Top Bottom Ft
Top Bottom Ft
11. DRILLING LOG
Top Bo/tom ,
Q/ Li
O
3a/ JU'
�3U1 ASS'
LSs0:
(5Z / No
t7o / (T0o'
/
/
/
Size
Ft
Mate L C
JUN 5 2012
Fggneaholt De~irynpbo
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12 REMARKS
hill
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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
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Up AA) i''),'S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
n.r____ - r. . -2—e_.- _L u,_a__ I+._ -