394116_Well Construction - GW1_20110513

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # A d a
1. WELL CONTRACTOR:
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Well Contractor (Individual) Name
��V�u�I►`5 Oett rilllr✓_C(
Well Contractor Company Name J
STREET ADDRESS - I Q.l i rl CSZ iri / 41
act,N1 , N a8aa7
City or Town State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT/1-(if applicable) 10"
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED /2_3a-/ /6
'TIME COMPLETED / — 3 - / / AM 0 PM I
3. WELL LOCATION:
CITY:
01h'Ao e COUNTY LiNlbhi
4I /4P 11 �r`IU RU
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope alley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3p L n�
LONGITUDE O 6 J
May be in degrees,
minutes, seconds or
• in a decimal format
Latitude/longitude source:1S ❑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 T
OWNER'S NAME 1. \iY
STREET ADDRESS 14(..D I k
City or Town State
n 9- 1 103
Area code - Phone number
5. WELL DETAILS: �D"
a. TOTAL DEPTH: V
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO LY
c. WATER LEVEL Below Top of Casing: /5 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.
r
e. YIELD (gpm): / 5 METHOD OF TEST //
f. DISINFECTION: Type /—// /7 Amount i`/C/
g. WATER ZONES (depth):
From %/ 0 To / ? ® From To
/J
From 7,5 To= P 3 From To
/7`
From }` . e) To 5 From To
6. CASING: C� �+j Thickness/ 49t�qa DTothq / Ft. CO �' / / Ar. /' e v.�
From
From To Ft.
From To Ft.•
7. GROUT: / Depth •ate . Method
From t/ To 3,5 Ft: �eti /" 7/'�� �l
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
FIT /0 1 ForrpatioV ss rptAn
I ` a 6 ' eUA) VI g A Li e
`0Uo'
j ' OA4' sXln%�
5/1 'P
,2o 0 3 o 0 / c,q i,-7 .e
060 ()tiOJ (TR /l?
yaa L.) 60 ' 3',4"
11. REMARKS: h- '.P
MAY 132011
Information Processnna Unit
1 00 HEREBY CER11FY TI-IAT THIS WELL WAS CONS? CCORDANCEWITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN
I►PRROVIDIDDED TO THE WELL OWNER. j /) %
SIGNA OF CERTIFIED WELL CONTRACTOR DATE
va 1) /u r) ti r')u i (- S
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