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HomeMy WebLinkAbout394111_Well Construction - GW1_20110513RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # 1. WELL CONTRACTOR: >��h (�!1u1(It Well Contractor (Indivi uaI) Name l rnLa I I.1CS l 1.� C I t vi 1 i trAi3 ell Contractor Company Name j1 STREET ADDRESS£ - City or Town State ip Code UL -731 5 C0 4L-I Area code- Phone number 2. WELL INFORMATION: SITE WELL ID #(if applicable) 0-T at --I STATE WELL PERMIT#(if applicable) DWQ or OTHER PERMIT #(if applicable) WELL USE (Check Applicable Box): Residential Water Supply 0 DATE DRILLED o 'c 5— 1 I TIME COMPLETED I rt Qc), AM PM 0 3. WELL LOCATION: 1� CITY: (2}1' X /+aIt) COUNTY efil) IPO fl) 9 I Co. (Q )aQ `S:-,d,� �►�,`, Pict (Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTJG: ❑ Slope :Walley ❑ Flat idge ❑ Other (check appropriate box) 0 LATITUDE 3 LONGITUDE (15 May be in degrees, minutes, seconds or in a decimal format Latitude/longitude source: GP ❑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 OWNER'S NAME (C1 rh CV' Cl be e_r- ST EET ADDRESS act I CO �}. QX her �r (v✓h'f 3 kQ'3 (NJ P�) ? City cr Town State Zip Code (�I OC) ): FL/3--:37 9 CC Area code - Phone number 5. WELL DETAILS: / c r a. TOTAL DEPTH: 3 6 5 b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0 c. WATER LEVEL Below Top of Casing: (Use "+" if Above Top of Casing) 406 FT. d. TOP OF CASING IS 1 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)• oC U METHOD OF TEST) I� 63i? ley f. DISINFECTION: Type HT /T g. WATER ZONES depth): From 3 7 2 Tq From To From To From To From To From To 6. CASING: Depth 1 C� �e M r From Q To /o1,SFt. From To Ft. From To Ft. Amount�- Thickness/ 7. GROUT: Depth Depth , Material From V To A Ft. �f")Yti �, From To Ft. From To Ft. (dh Method �DeoI 8. SCREEN: Depth Diameter Slot Size Material From-3o Ft. in. in. From To Ft. in. in. From To Ft. in. in. 9. SAND/GRAVEL PACK: Depth From To Ft. From To Ft. From To Ft. 10. DRILLING LOG Fr. To /DD ` NO' 11. REMARKS: Size Material Foi ati Desc '.tion .4 ( .1Pre ' s Agdnfrated e MAY 13 2011 Infnrrnohr n Processstnq Unit DWQ/BOG 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. I f)?, .,- .LC.e cQ a 5-i / SIGN RE OF CERTIFIED WELL ONTRACTOR DATE CD—C) 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. (919) 733-7015 ext 568. Form GW-1a Rev. 7/05