384420_Well Construction - GW1_20100610

North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
L,��
Well Contractor Company Name
c u � H�►1 R d
reet Address
c art �+- - N c� c 'ce2r7
City or Town _ D _ State Zip Code
(I H) `�� �-, w
Area code Phone number
2. WELL INFORMATION: {' p
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #Qf applicable)
3. WELL USE (Check Applicable Box). Residential Water Supply [�}�
DATE DRILLED 3 - /J1 /O -
TIME COMPLETED- 3„ 3 0 AM p PM t ►
4. WELL LOCATION:
CITY (i ita/1/9GU COUNTY C/N,bfV
Lc a, L�thct-,_) 1.ncilat., Pd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING: (check appropnate box)
❑Slope ❑Valley ❑Flat ilefirige ❑Other
LATITUDE 36*c.39 9Y2 " DMS OR 3X.X000xxxxx DD
LONGITUDE 75 3'3 9? " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 WELL WNER
i Oh eR l 6 $80N,'22 f9
Owner Nam
Oci
Street Address
c):43-\ , NCJ as r,73
amity or Town
(f7( \) `So 1-(---1n1
Area code Phone number
6. WELL DETAILS: 6
a. TOTAL DEPTH: �-R `
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ID NO L9�
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). %;Z METHOD OF TEST_
f. DISINFECTION: Type / /7./q Amount
AO3 s>
RESIDENTIAL WELL CONSTRUCTION RECORD 3
1. ido
g. WATER ZONES (depth. ' F
Tope Bottom A 5 S Top t o 1 n 11,Bottom
Top / 2S Bottom / 570 " Top
u
Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth rf Diameter Weight
Top 0 Bottom / A3 Ft In lg, + 1 S
Top Bottom Ft
Top Bottom Ft
Material
PU,C,
8. GROUT. Depth r Mate "al Method
Top 0 Bottom A Ft Befuloomto ///9ecJ
Top Bottom • Ft /
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft in. in
Slot Size Material
in
in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft.
TopBottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
D / 70
70/JOG
'
JOG `/ /023
/A3 / /66'
/60 / a at5 =
--
/
12. REMARKS:
Size Material
r atipn Descnption
A e
SA
S,9n-e
�u1 0 101U
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.
�)s/6
SI ATURE OF CE TIFIE WI NTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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