389703_Well Construction - GW1_20101201

RE.SIDEN7'11E WELL CONSTRUCTION RECORD
Norm Carolina Department of Environment and Natural RosourceS- Division of Water Quality
WELL CONTRACTOR CERTIPICATLON.#
1. YELL CONTRACTOR:
re--1 4t3Vki
\y Eli CanuxLJr ( atv uaq 11
C` -lt'J* LL UVeOE
well Conuscw( Cam•- Nsma
STREET ADDRESS O a �Z
.,,i_D d S 1- /1)( . c... a S 0?i
CiN
ar Town
Stale Zip Code
_7 _ %TY 25L�3
Area ewe- Pnone numD2r
2. WELL INFORMATION:
S IT E WELL ID Trill :ypliCiDid) V a ZZ
STATE WELL PERMITtr(it.ppbcaota)
OWQ or OTihER PERMIT >♦(ii applicable)
WELL uSE (CnaiiKjjApplie-aolle Box): Residential Wier Supply € —
DATE DRILLED I l i (8- aC} 1 G
TuaE COi4PLETED , •OD AM E PM —._--
3. WELL LOCATION:,
CITY:1x vkircSINJ:� COVNTY V\ Sr.J
`) e I- Old w,ie
IStrta r ima, NtanD415, Community, Subaivicion, Lol NAS, Parcel, Zip Cone)
TO_ PPOOGRRnPtitC / LAND SETTING:
L751ap� OVauey QFtat QRitiga pother
tC112CK appropriate boa)
LATITUDE 3 S ro (8..5'
LONGITuOE 8 - a 6707.:
Latirudeilongiturit source: e pTopographic map
jixs:an of way must oa shown on a USGS lopo map and
aaacnaa to mis roan it nor using (.3PS)
;. WELL OWNER
OWNER'S NAME ester-c-k-k e . V 1.... u Id --
STREET ADDRESS ta t 0( „St A. c A ,1
1,1
6\A2SL..!:kt( �)' Zij'( O'S L
City or Town State Zip Code
Z5 �3/V1.
Ass cwo - Pnone nurnoer
May be in dcercrs,
minutes, seconds or
in a decimal format
AilAAL.
3Ais !f 33
f. DISINFECTION: Type ( S Amount \ L
9. WATER 7rONES (depth): • i
FromC‘.d To \ Q‘O From
From, ! To -' From
From To From
6. CASING:
Fro 4- i
From
From
5. VaELL DETAILS:
a. TOTAL DEPTH:
Lk o
b. DOES WELL REPLACE EXISTING WELL? YES ❑ N0
WATER LEVEL Baloer.Top of Caning: FT.
Wu' T d Above Top of Casing)
a. TOP OF CASING IS , i FT. Above Land Surface
'Tap cd casing terminated allot below Yana suriace may require
variance in accoraanoo vrith 15A NC.AC 2C .0118.
I. YIELD (9Pm}: ZZ METHOD OF TEST ��—
To
To
To
Thickness/
Oapth� _,` ` ,Cliarr1�r Weight Material
TalflU FL La,
To Ft.
,To FL
7. GROUT: Depth uteri
From a ,To Ft he�
From To FL
From To FL
Method
Li. SCREEN: Depth Diamater Slot Size
From To Ft, in, In.
From To FL in. in.
From To . FL • in. M.
9. SAND/GRAVEL PACK:
Depth
From To FL
Frorr To FL
Size
Material
Material
From To Ft.
10, DRILLING LOG
From To
D
o_Flmation Description
E C E EL
DEC 0 1 2G1O
Information Processttty unit
1.1. REMARKS: DWQ/BOG
1130
15A
AEC
FIE CE1YTIiAT11115 WELL WAs CONSTRVCTEP ACCoRtAN'.E W1114 '
2C, WELL CONSTR=10N STANMROS, AND A COPY OF TtUS ,
HAS9EENPROVIDED TOT EWELLOWNER.
SIGt7ATURE
Chit
-2,0
iFIED WE¢L/CONTR?ICTOR DATE
PRINTED NAME OF PERSON CONSTRANGTFIE WELL
Sunmit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,,
1617 Malt Sri Center— Raleigh, NC Z7699-1617 Phone No. (9191733.-7016 ext 568.
Form GW•1a
Rev. 7/05