394108_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:
Irk S
Well Contractor (Individual) Name C '
� C. (�LI, \ U eI( Tjhv
ell Contractor Company Name'CAINa
STREET ADDRESq () A\ Cal r C ht I lrra'
City or Town ,ate Zip Code
reams e Phone nce3�g4
2. WELL INFORMATION:
SITE WELL ID #(i( applicable) STATE WELL PERMIT#(if applicable) / I a Va
`
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable
Box): Residential Water Supply ElDATE DRILLED LJtav` /
TIME COMPLETED Sib U AM ❑ PM
3. WELL LOC ION: [�
CITY: Q.�d i 0-1--k ^ COUNTY ei%UitDni
I`j() t (3''cl 7r
(treet Name, Numbers, Commu y, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPFjJC / LAND SETTING:
❑ Slope, alley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3
LONGITUDE 0
Latitude/longitude source: GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
May be in degrees,
minutes, seconds or
• in a decimal format
4. WELL OWNER ` ((�� �,,,��
OWNER'S NAME Il I I a-C,�1r-) Lil'OSS
� � ADDRESS I CiAll � c t An "all
City or Townes State Zip Code
Area code - P one number
5. WELL DETAILS: ���
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: a 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): 0 METHOD OF TEST ai t-
3 -°�I�-
f. DISINFECTION: Type N —r-J+ Amount \ p4-
g. WATER ZONES (depth):
From 65 To 9 6" ' From To
From 9 `7 To G/ 45 ' From To
From 11 S' To j a y From To
6. CASING:
Diameter Thickness/
From l ) Depth
� Ft. (y Weigr tenal
L LIr b ?l IUC1
From ' To Ft.
From To Ft.
7. GROUT: Depth
From To cQ Ft.
From To Ft.
From To Ft.
Material
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
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
c ()`
Ltc\—
1-I LI '
11. REMARKS:
Material
Formation D scription
R 1c.�+
C^—r.rs.
c'tS le. t'Jmnnit-e_
�=,rGt� Gt ✓� n i tC.,
i V►4 71 i 1�
10 IC— r' Er_ li ®
2G11
Information Processing Unit
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.
r► 02.2-/I
SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
Jo r2, mirA.43
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