384419_Well Construction - GW1_20100610

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Weii uontractur (individual) Name
c- rvl u s (e. i) 'Thy; i) I'A19
Well Contractor Company Name
q ary. bus �t c� 'No 1 o?
Street Address
C ha�lc � Alm. a3a7
City or Town State Zip Code
('7OLi) .cL/5-- 610
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# t) t/ D 3 000 9 9
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Suppl ,❑
DATE DRILLED A - a 3// - / c T / i'1 r,5, AT> bN
TIME COMPLETED- a "a I - / Q AM ❑ PM
4. WELL LOCATION CITY: AA A'e&)5 COUNTY L/%Nt aN
(Street Name, Numbers, Com
c)st Cr.Alatex C�a +�
nity, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND,SETTING: (check appropriate box)
❑Slope ❑Valley L+`r-at ❑Ridggeep ❑Other
6' LATITUDE 36 " r?? 116 87 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 " Dv ' yy, 013" DMS OR 7X.X000XXXX DD
Latitude/longitude source: 1S Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Owner Name
Stet Address
I V Ct ") C_
City or Town / [ a
CLOji
UO
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 3 k.
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? 7YES ❑ NO tp�
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): 9c_5" hi/
OF TEST
f. DISINFECTION: Type l/ / /9 Amount .)•-ef/)
a la AI(
e
g. WATER ZONES (de th):
Top O' /J Bottom 2. 0 Top
Top_?3 ... Bottom 0/ S Top
Top Bottom c3.,2 6 Top
7. CASING: Depth ��Diameter
6D� m��
Top 0 Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
Weight aterial
Material Method
/5 Ft. :C err m u/ p cpe1
Diameter Slot Size Material
10. SAND/GRAVEL PACK:
Depth
Top Bottom
Top Bottom
in.
in.
in.
in.
in.
in.
Size Material
Ft. re�
Ft. \^ ,,', ILj
Top Bottom Ft.
11. DRILLING LOG
To Bottom
'//�f
,;C5
3 / cTo
/ -
rS� / Gov
/
(o / IYd
JJO/c26br
h b / . 3a5
JLlh 1 2010
Inbre'7' gild"' IDes'cri tiori)f3f3
eiP iiCS y
i� q)
f%rU
hi 1
la 40 /U
do a /L)
4 . LU , `P
12. REMARK:
tr\ ect c r
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 ATURE OF CERTIFIED ELL CONTRACTOR
So J lv 0'1 in ; 5
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
n..L,u. ___:au_ nn .____ _e — —I-:_e uit_a__ a.._cs._
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