391402_Well Construction - GW1_20110513

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # •03S
1. WELL CONTRACTOR:
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Well Contractor (Individual) Name
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lc_ mui1►5(f .lJ 11frw •/v
Well Contractor Company Name
STREET ADDRES� S(t�-�x CSL Nt f 1 /CA►
to c %
City or TT 4Sttatee �% / Zip Code
Area code- Phone number fl
2. WELL INFORMATION:
SITE WELL ID #{d applicable)
STATE WELL PERMIT#(irapplicable) t ' - a
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply 0
DATE DRILLED 3
TIME COMPLETED i 6 0 AM ❑ PM L ' -
3. WELL LOCATION:
CITY: 4/AX /164 6(J COUNTY U-h) Dr)
C,1nI7R OAKS OR
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, ZJp Code)
TOP GRAPHIC / LAND SETTING:
ope ❑Valley 0 Flat 0 Ridge 0 Other
(check appropriatx
Ge
LATITUDE 3 ,11 33
LONGITUDE S Q L
Latitude/longitude source: PS ❑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
May be in degrees,
minutes, seconds or
• in a decimal format
State
`! (D29
Area code - Phone number
OWNER'S NAME IC e�� �i-} el
S FLEET ADDRESS 6)CR. n.
1/72)
Zip Code
City or Town
5. WELL DETAILS: f7A
a. TOTAL DEPTH: / ()
/ t!
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NCV
c. WATER LEVEL Below Top of Casing: 3Q 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): "i" _ .JIETHOD OF TEST OJ
,1106Z
f. DISINFECTION: Type •4 I Y7
g. WATER ZONES (depth):
From U To c 5' ,1 From To
From To From To
From To From To
6. CASING: Thickness/
From Depth L� Ft. Dpmgtgr (.0 , �j / j� 0 We OM J j v C'
From To Ft.
From To Ft.
Amount
7. GROUT: Depth t�Material Method
From 0 To ill FL TriYi-Dli 111.m )- et,
From To Ft: 1 f
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From TA 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
Fe • Tie,
S&UT 760'
11. REMARKS:
atio - Dgription .
K � . i--- z !! .r— 11 9
MAY 13 2011
Information Processing Unit
UWU/t3tXj
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,
reh
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
�c n mu I Vs KCIui� 3e%lC
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
L>
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