384417_Well Construction - GW1_20100610

11
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. FLL CONTRACT
Well Contractor Individual) Name
�
V1ell Contractor Compan ame
qa (j3 i Ir-- -. - 1; )1 R
Street Address
CharIb�-
City or Town , - State Zip Code
()1) e)- 5(0
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# (`} V- /97
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply lie'
DATE DRILLED / rX "�" O
TIME COMPLETED: / A- 9 -O 9 AM ❑ PM f
4. WELL LOCATION:
CITY: tr% (AP) A b e COUNTY Uft/r .0/2J
Lfrck.vx.CG���:, Um --a
(Street Name, Numbers, CommunttS,, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley flat (3 Ridge oOther
LATITUDE 5' /(p o/'7 " DMS OR 3X.XXXXXXXXX DD
�'Op
LONGITUDE O 03(1. / "DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source:S Ofopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
s I
rName
Own
31 (- ' .d
Str et Address
City or Town State Zip Code
2> U C3 5
Area code Phone number
6. WELL DETAILS: /
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO IV
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.
e. YIELD (gpm): lMETHOD OF TEST
f. DISINFECTION: Type j7 %y Amount (.2_c3
96,362
�a, aoic�t(
3E) 4 41 7
g. WATER ZONES (depth):
Top 6 Bottom 86 Top Bottom
Top /b0 Bottom % /0 ` Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth •
Diame er Weight /atenal
Top 0 Bottom ,....5-6 Ft. / , r S r ( )
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 30 Ft. !'7oU%C/ttee
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
in.
in.
in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
in.
in.
in.
Size Material
11. DRILLING LOG
Top Bottom
/61
/0 / ab'
( 3L5",
3S /,rr`
,17)1 l /66'
ROO' l 366 ,
/
/
/
/
12. REMARKS:
Formation Description
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tIL)
tie , 7e
-(4/e L1. i*
Ae,,v c5Aigir
�ejive
+� L.( V L,.L?
JUN 10 2010
Informatson Prac:assing Unit
DWQ/BOG
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.
krlil E OF j FI ELL
CONTRACTOR
SIGN RE OF CERTIFIED ELL CONTRACTOR
DATE
�hn rY1L-st-t 1 + s
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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