384432_Well Construction - GW1_20100610

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # d 3 d 3
1. WEELLL ONTRACTOR:
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Well Contractor (Individual), Name
r _m(aik.V_S QII rb6)1N
Well Contractor Comp Name t 9
CiaC9� ,.r c 1— R) I 1 12 c1
StreCleo, Address,
o-.\--
N C_,agea7
City or Town r (0, I State Zip Code
('10y
() 5'-- 3 9L1
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# /6 — 76
OTHER ASSOCIATED PERMIT#(dapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply [--
DATE DRILLED L S—/ 0
TIME COMPLETED' i 3 0 AM ❑ PM
4. WELL LOCATION:
CITY- OtJF)X////4)
COUNTY y/1v10 I'l)
(Street Name, Numbers, Community, Subdivision, of No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ID Valley Bt-iat ❑Ridge ❑Other
LATITUDE ap39'J,r vo/DMSOR 3X.)00xxx(XXXDD
LONGITUDE le *ift' W457S" DMS OR 7X.X00000000X DD
Latitude/longitude source: V6PS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
11 )( PC r)Ck)0A-Icrl
6wner Name
cS3 r4L rK_
v
Street Address
r,,Nc_ ay) 9
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: A0o
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: SO 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 vanance in accordance with 15A NCAC 2C .011181 p
•
//
e. YIELD (gpm): / CJ lM�ETHOD OF TEST i7//\
f. DISINFECTION: Type %N Amount /
L' x
9. WAARVONES (de): ,
Top / Bottom / " Top Bottom
Top l % Bottom / 9,5- ' Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth `` Diameter Weight
Top 0 Bottom fTII O Ft Ln YfQ ,/2.$
Top Bottom Ft.
Top Bottom Ft.
8 GROUT: Depth I'
Top 0 Bottom 35 Ft
Top Bottom ' - Ft.
Top Bottom Ft _
Material
8eiu%lie
Material
'RUC
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 Size
Top Bottom Ft
Top Bottom Ft.
Bottom Ft.
Top
11. DRILLING LOG
Top Bottom
Q / 80
/ /AO
ia6 / /yo'
/5/6'i //a
/t,O l / o
/o / -.2,60•
/
/
12. REMARKS
enal
JUN 5 2ni?
Formation Dgescription
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iRowr) (NAMe
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L,/97-e
'JUN 1 0 2010
lnfn,-.,
_ SSlrin 1I.,
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.
i'7' /' ,I� ( "/ O
SI TURE OF CERTFFI D WELL CONTRACTOR DATE
Jo A Pi ii)14
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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