399091_Well Construction - GW1_20111027

RESIDENTIAL WELL CONSTROQTION RECORD
Noon Carolina Department of Environment and Natural Resources -Division of Waft!" Quality
i1
WELL CONTR.v.CTQRCERTIFTCATl.ON,##
1.' WELL GONTR.2,CTOR:
v-u C.:orur^tat tnQiv44 ,ma
oC -k 0,R We( t 1 .
wen Contra`wr compan Le
_Narita i
STREET ..DDRE53.0 0 v E L
i—ociAsq \. C. Z, 3 b i -?
Ci(,or T9r,rn Stare Zip Cone
;70VI- $5'$,-2s//5
,wP Pnorle mamba
2. YYELL INFORl TI0u:
-SITE vk ELL ID 8t1( applies/so
E WELL P ERMITittu applicanto )
DWQ or OTiiER PERMIT ifif =pplicablel
%Y EL. LJ E 1C1 ' Appticiole Box): RasiLenlial Water Supply
DATE DRILLED t I- Z.
TItaE C041PLETED 4 ► O 0
AM Q FM—
. WELL TION:
CITY: ti 4 (L,z ` COUNTY Vl i1 4
Ixrfat N:rhs, ttwnar: ., Csrnmunuy, Suoa;visian,`,0 ti9., P ae{, Zip Code)
TOPOGRAPtitC f LAND SETTING:
OSIQ9d OW.n _
y I`I: QRia9e O0ther
tc(1asn ittprapnaie box)
L�.TITuOE 3 JrL
LONGITUDE . 0 ` 3I
City or Town State
7�-�,_ 76
.era -a cwa - Pnonz number
a-. WELL DETAILJ:
_. TOTAL DEPTH: 3 e 0
D. DQEJ WELL REPLACE EXISTING WELL? YES C! NO Q
May ix in dtgrecs,
mirttttc9, s;CQnds or
in a decimal inrmat
t.:rritudellon4ittide sourea: S LQTopographic map
frocsrbn or t+6u must oa mown co a tiSGS tope map amp
.nscn_a Io to loam % nor using GPS)
i. WELL OWNER
01Y'NER'S' NAME O ,- (} j l e
STREET ADDRESS ..58
e. \j ebttZ
Zip Cocle
7Z.e
c. tiY:+TER. LEVEL 6e1ori-Tap of Casing: O
(Vie'* ' ifAboveAbove To of C "'�'
acing)
Q. TOP #
4F CASING IS
----_ FT. Above Land SuftaCo'
Top ot inQ terminatiAl auor below lamb surface may requ'ue ii v.tiance. in accordant:a with 15.'. NCAC 2C .otla.
'Y OPml: UO T teETH00 OF TE$T_
ff
399091
f. DISINFECTION'.TypeTii\ekS Amount
g. WATER Z0NES tdagth):
From 5/ O To b c
From To
From To
S. CASING:
From
Frarq
From
From To
From To
From To _
Thickness!
Dem ► Di er Weii9h a ial
To f 3 Ft. 'f; I C-.
Tv Ft.
To Ft.
7. GROUT: Depth r at2lt
From 0 To FL Na A+ �E
from To Ft_
From _ To Pi._
Method
9. SCREEN: Dept) Diamster Slot Size
From To FL M. In
From To FL in. in.
FromTo - FL -in- in.
9. SANWGRAVEL PACK:
Depth
From To Ft
From To Ft_
FUMY Tp
10. DRILLING LOG
From To
0
G0 s
11. REItiAR1iS:
Malarial
Size Material
FOrmatlon Description
d r
a
F
- FD
ULJ 2 / ZOil
taforrlation f^rtic6SSti1Q Unit
DWQ/BOG
I DO HERE
15A He
DECO
Y CERTIFY THATithiS WELL WAS cOnSTRVCTED INACCORQANQE Pahl '
e WELL CONSTRUCTWNSTANDARDS,AHD 111ATAGDP
Y,RF1hi i-
FIA3 BEEN PROVIDEDT01KE WELL OWNER.
/0-I -Gc�
SIGNATUREF CERTIFIED WE t:ONT CTOR DATE
PRINTED NAME/OF PERSON CONC IN THE WELL
vUmit tn'4 original w the 4iVISiQ11.of Water Quality within 30 days. Attu: information Mgt,,
1c11 mail 5ar�ic6 "nlfr— R�l�ig4, NC 27695.1617 Phone No. (4191733.7015 axe 565,
Form GW-la
Rev. 710