384423_Well Construction - GW1_20100610

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTT TOR.,CERTIFICATION #
1. WELL QNTRACTOR:
Well Contractor Individual) Name
0, k s v�eij bn \ 1 I/Qq
Well Contractor Company ame
acn J
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et Address
J1c^c e02.27
City or Town L� State Zip Code
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Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 1 3 —
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply
DATE DRILLED 3 ' /g iD
TIME COMPLETED: 3 -8 /6 AM 0 PM
4. WELL LOCATION:
CITY: CcJAkJ`/ACOUNTY //Ni O /U
ss ) /1-E-
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropnate box)
['Slope ❑Valley ❑ Flat I�rcidge ['Other
LATITUDE 03 / 57«/9 " DMS OR 3XJ00o00000C DD
LONGITUDE 75Sa "VI (1 " sMS OR 7X.)00000000( DD
Latitude/longitude source. ►' ' S Qfopographic map
(location of well must be s own on a USGS topo map andattached to
this form if not using GPS)
5 WELL OWNER
rv\. rm 3 m
Owper Name
Street Address
c, �lnaw D�1G 1ri.3
ity or own State Zip Code
n(\) Co (-I - L--1 C)) �I
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: p 0 0
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing. 35
(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). AS METHOD OF TEST it/
f. DISINFECTION: Type NT,/ Amount /
NO143—
FT.
g. WATER ZONES (depth).
Top % 6 Bottom '
Top P 5 Bottom / 6 5
Top Bottom
7. CASING: Depth E Diameter
Top 0 Bottom 76 Ft. 6 '/'
Top Bottom Ft.
Top Bottom Ft
3
A
Top Bottom
Top Bottom
Top Bottom
Thickness/
Weight //✓M'atlerial
ira5 / 12C
8. GROUT- Depth r Material
Top 0 Bottom 35 Ft geiv/O/b, fie
Top Bottom Ft
Top Bottom Ft
Method
/''p d u
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 Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
D36 / `
Jbo
cS6 / (tS
6 6' l 761
70 / /66►'
/001 ,26c>
/ --
/
/
12 REMARKS:
o ation II es • tion
G.
ii ins
Buie K i LOW
Informai,u
_/aSing Unit
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.
il . .ma y' 3- / 9- /6
SIGN URE OF CERTIFIED WE L CONTRACTOR DATE
(Toil n) P 1. /114 J,A,5
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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