394118_Well Construction - GW1_20110513

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 0 .3 e
1. WELL CONTRACTOR:
I 1 u I ll`s
Well Contractor (Individual) Name
Well Contractor Company Name
STR ET ADDRESS
C�a�-low._ /Uc,
Ci or own Slate C Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) p
STATE WELL PERMIT#(if applicable) // / /
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED j— // 1 `5 —// L�" /
TIME COMPLETED �l / 30 AM PM ❑
3. WELL LOCATION:�t
CITY: LIJ�I Xif/91A) COUNTY UN/ ON
1 r9o9l 64e/vdetJoru cT
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC /L�A�D SETTING:
❑ Slope ❑ Valley Vat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3,5 1I
LONGITUDE d
Latitude/longitude source: nfie3S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER 7'
OWNER'S NAME C fik /ii e /'1.4Lo/u e
STREET ADDRESS t t 9& e/UC/eoOn) C r
May be in degrees,
minutes, seconds or
• in a decimal format
W4xIfl4uw N. c a$'j'3
City or Town State Zip Code
( 70`f) a%-85a/
Area code - Phone number
5. WELL DETAILS' O
a. TOTAL DEPTH: Y�
b. DOES WELL REPLACE EXISTING WELL? nYESS ID NO
a( (
c. WATER LEVEL Below Top of Casing: �J 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): / ,Q METHOD OF TEST fi r�
f. DISINFECTION: Type /7 %77/
g. WATER ZONES (�depth�
From 3 To .J �
From y02b To .30
From 30 () Toy S From
Amount 2 P,iuT
From, s46 To J /
FromJ %0 To J9\5-
6. CASING:
Depth /,' Diameter
From 0 To 6or Ft. /o
From To Ft.
From To Ft.
To
Thickness/
WeigFjj Me� IG
7. GROUT: Depth n ' rial Method
From 0 To A 0 Ft.
From To Ft.' _
From To Ft.
8. SCREEN:
From
From
9.
From
Depth Diameter Slot Size Material
To Ft. in. in.
To Ft. in. in.
To Ft. in. in.
SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
D' AO'
.20' �36'
30 sr)
LT" 6'6s��
69' 366
106 r 666
11. REMARKS:
/fired mationCA4y n
SGlA-.l'�.
X c5Zi4-T; r�
ftaw.e rf
J7
,5/L m f
MAY 1 3 ?nil
information h'roccssirly ur;n:
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.
SIG TUN CERTIFIED WELL CONTRACTOR DATE
v'(A ry P7 /''2uk, 3
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. 7/05