384428_Well Construction - GW1_20100605

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Li 1 1.1f5
Well Contractor (Individual),Name
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Well Contractor Company me
St eet Addres
City or Town State Zip Code
(I'DDLqg
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# CO — a a-O
OTHER ASSOCIATED PERMIT#{if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED L\-1 G-10 -1-rys 3 Q (y)
TIME COMPLETED' 1_ 1 "I— IC) AM 0 Ply
4. WELL L CATION:
CITY. \ \�i% \ COUNTYR k LY)
�/��.J �ref 1 I Sty
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOG
PHIC / LAND SETTING: (check appropnate box)
pe ❑ Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE Egi�>35' D ' fJ�,(t r% " DMS OR 3X.XXX XXXXXX DD
LONGITUDE b V °' F4 '004 " DMS OR 7X.xxXX)0000( DD
Latitude/longitude source Qfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. W.,1.L OWNER
'2.83
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Owner Nail
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Str t Address J
C. V. N a§1a5
ity or Town State Zip Code
oA- 9 C) ( a a(2.?
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: )
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOG1//
c. WATER LEVEL Below Top of Casing 1 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS I 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) c,2 METHOD OF TEST C9---1.1
f. DISINFECTION: Type ,\ T 1--k- Amount \ () fit"
3t.44
g. WATER ZONES (depth)
Top y Q ` Bottom (---14--) i Top Bottom
Top V 0 " Bottom `a0. Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
Top 0 Bottorn;2 ( Ft Cn ,/ S7
Top Bottom Ft
Top Bottom Ft
Thickness/
Weight Material
2u'c
8 GROUT Depth r1 Material
Top l J Bottom r,c 0 Ft BC it 104'11` 1'Ci
Top Bottom A Ft
Top Bottom Ft
9. SCREEN: Depth
Method
Diameter Slot Size Material
Top Bottom Ft in.
Top Bottom Ft. in
Top Bottom Ft in
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft
Top Bottom Ft
in
in
in
Size Material
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/ 10`
ao / ao
a?(( /
/
/
/
/
12 REMARKS
Formation 1 r
?nRtton
vCYL\..53'1 C, (51 r 1 I
R Cici<
ELC
JUN 5 2012
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
mil, r u-Za ' 11-17-1
SI URE OF CERTIFIED WELL CONTRACTOR DATE
J(Th\ in r o i i 1 S
PRINTED NAME OF PERS N CONSTRUCTING THE WELL
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