394107_Well Construction - GW1_20110513

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ,-2.03
1. WELL CONTRACTOR:
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Well Contractor (Individual) Name
�L m u) ► ��) I J�,)I I'w5,n�C1
Weil Contractor Company Name
STREET ADDRESS'1)1 . 1) VU( ttt CSL NI l 1 ICE
0-1-11-Acy1-4, N 1 i c r 7
City or Town State Zip Code
(icy-1 )- 54 ' 5(6 96/
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(if applicable) t 1 - a 7
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply Cl
DATE DRILLED 3 -2 3 -1
tr
TIME COMPLETED . / 6 0 AM ❑ PM [4-
3. WELL LOCATION:
CITY: 19AX gig U) COUNTY 11 j D
C1Nne, 0 / S OR
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP dGRAPHIC / LAND SETTING:
ope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
(check appropn'at p3
LATITUDE 3 ; ,
LONGITUDE
�Q G
May be in degrees,
minutes, seconds or
• in a decimal format
Latitude/longitude source:S ❑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
]A
STRvEET ADDRESS C9
UJ NCB
State
(G )LI) O qq (029
Area code - Phone number
City or Town
5. WELL DETAILS: 7 A D a
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ Nt7
c. WATER LEVEL Below Top of Casing: 30 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 .01118.E
e. YIELD (gpm): Q.gncI METHOD OF TEST W.,
f. DISINFECTION: Type 4'1 l 4
g. WATER ZONES (depth):
From 0 To 5,5
From To
From To From
From To From To
Amount
To
6. CASING
Thickness/
Depth Di/��m�t r Weihe7 Material
From 0 To L) Ft. (? �/ , Pl3 0 i' jf ,
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To r20 Ft. ili iVI; Dil.,v. /k- (1,
From To Ft. J t
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
From To
From
From
Size Material
Ft.
To Ft.
To Ft.
10. DRILLING LOG
=....x rt./ 1
11. REMARKS: MAY 1 3 2011
Information Processing Unit
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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 ' 1 3-a - I /
S18NATURE OF CERTIFIED WELL CONTRACTOR DATE
--3—Chn 111uiUisejfl'ciu cIAC
PRINTED NAME OF P RSON 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