390109_Well Construction - GW1_20101217

RESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3242
1. WELL CONTRACTOR:
Larry Tucker
Well Contractor (Individual) Name
Tucker Well & Pump Inc
Well Contractor Company Name
STREET ADDRESS 3150 Centergrove Rd
Kannapolis NC 28083
City or Town State
( 704 )_ 932-3296
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
3. WELL USE (Check Applicable Box): Residential
DATE DRILLED 9/20-21/2010
Water Supply 0
0 PM 0
Union
TIME COMPLETED AM
4. WELL LOCATION:
CITY: Wingate COUNTY
1902 Musslewhite Rd
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source: 0 GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. WELL OWNER
OWNER'S NAME Vanderbuilt Mortgage
STREET ADDRESS 1902 Musslewhite Rd
Wingate NC 28174
City or Town State
( )-
Zip Code
YES 0 NO 0 .
FT.
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 300
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 30
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above
Land Surface*
surface may require
2C .0118.
TEST blowing
*Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e. YIELD (gpm): 6 METHOD OF
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From 260 To 300 From To
From To From To
From To From To
7. CASING: Thickness/
Depth Diameter Weight Material
From O To 50 Ft. 6" plastic
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0 To 35 Ft. grout pump
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
11. DRILLING LOG
From To Formation Description
0 1 topsoil
1 10 yellow dirt
10 _ 40 sandrock a® Bid'
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40 300 grey rock ` I� I - I. Id rl"" Li
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12. REMARKS:
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.
Larry Tucker 10/7/2010
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Larry Tucker
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-la
Rev. 3/07