391316_Well Construction - GW1_20110208

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Oepdrlmcrll of Environment aria Natural Resources- Division of Warty Quality
WELL CONTRA,CTQR CERTIFICATION.#
1. iv ELL c.ONTRACTOR:
tk K..( , ( N cs- ,
�W-U Conttactor (/not u-I Name
,€5 {� 14`A'�`i{ CC
v\ eU Conuacwr Qom - Name 1 (/ �
S REET .ADDRESSt , D r E `lt rt �)`'
y� i, or TQ nStatF Zip Code
q 1J 1- g�' 2-$1/-3
.,,raa ccaa- Phone numoef
2. WELL INFORnt:;TION: . SITE vv ELL ID i(if applicS\Qla) 0 —7 39
STATE WELL PERMIT>tlirappticaotal
DWQ or OTriER PERMIT i(if applicable)
WELL USE (Cried: Applicaole B : Residential Wafer Supply
DATE DRILLED )a — /. z v / 0
TIME CCI it 0 O AM ❑ PM'-
3. WELL LO ATION:
CITY: NEW Sr- 10 (41 COUNTY uv..\ ---v36
n ti0 I ( 0_k1--d
(Strict Niglio, NufQcrz, Community, SuQaivision, LQI NO., ParckI, Zip Coat) '
TOPOGRAP . ICI LAND SETTING:
ope ()Valley °Flat °Ridge ❑Olhcr
(enecK appropriate box)
L=,TITuDE 3 (� -7 minutes, seconds or
07/O� Mayte sdcndso
LONGITUDE 6 O° / / , {-3 in a decimal former
Litiardellaneitude source: ,.O.rrP$'`pTopographiC map
(IocaLisn of - u must Oa snown on a USGS Iopo map and
enamel to Ins term it nor using GPS)
;. WELL OWNER
OWNER'S NAME a- A N e
ttQ
AD
STREET RElSS " cK �� �2 )s
Mc/Jr-�IR_
R-c4e,L SEC. 7. S7s
Cir-or Town State Zip Code
g3)- 7,'7 —060o
Area ccaa - Phone numoer
5. WFrLL DETAILS; /
a. TOTAL DEPTH: 1 Z
b. DOE? WELL REPLACE EXISTING WELL? 'ES-e-11175-
c. WATER LEVEL Biow.Top of Casing: l C FT.
(Via - ' if Above T op of Casing)
a. TOP OF CASINO' IS `(. FT. Above Land Suflace'
'Top of casing terminated falai below lama surface may require
a tiriarlce in `-Cordance with 15A NCAC 2C .0118.g
e. YIELD Wpm): `,..:)-5-METHOD OFTE$T .A (K..
0
u 0 � v
r. DISINFECTION: TypeI
yp i � �� �� Amount
9. WA ER`O»ESF(depth)_/
:.From 1 S To I CA) From To
From To From To
From To From To
6. CASING: n Thiickness/ �f
From Torte,i- 0Ft. J.L�B�C-4(w(o9��g rVI��'--•
From To Ft.
From To Ft.
7. GROUT: Depth ) Material Melhocl
From 14:J To JJ FL
_ •
From To FL
From To_ Ft.
E. SCREEN: Depth Diameter SlotSiza Malarial
From To Fh .- i Tin. In,
From • To Ft: in. in.
From To I. in. in.
9. SANWGRAVEL P CK:
Depth Size Meerut
From To F
,
From To FL
From 're Ft.
1I), DRILLING LOG
From To t Formation Description
— i' ' c a c/ v da j C,-
()( /4D 1--)orle(
,-
itOF, • Ff
•
11. REMARKS: N
DER rL,hPrntY.:,.., tt.,Urlit.
lop HEREBY CERTIFY THAT -IRIS WELL WAS CONSTRUCTED IN ACCORQAN1.E WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF ._------ -
RECORD HAS BEEN PROVIDEDTO THE WELL OWNER.
•
SIGNATU OF CERTIFIED LL CO TRACTOR DATE
C -)0 t., -(
_
PRINTED E OF PERSON CONSTRUCTING THE WELL
Supmit the original to thG Division of Water Quality within 30 days, Attn: information Mgt.,
1017 Mail Sri Center— Raleigh, NC 27699-1617 Phone No. [phone] axl 568.
Form OW-1a
Rev. 7/05