394111_Well Construction - GW1_20110513

RESIDENTIAL 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. [phone] ext 568.
Form GW-1a
Rev. 7/05