394103_Well Construction - GW1_20110513

1. WELL CONTRACTOR:
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• Well Contractor (Individual).Nam�e �
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I Contractor Company Name J
STREET ADDRESS"le4 l f. a.tr- C SI„ I-4 I I / fed
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City or Town State �
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Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ff applicable)
_
STATE WELL FERMIT#(ifapplicable) / I--
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check ApplicableblBox): Residential
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DATE DRILLED ell/cJ -- //
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Water Supply t�
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TIME COMPLETED y- le- I f / AM
3. WELL LOCATION: ((��
CITY: WAX (fI 1()` COUNTY
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(Street Name, Numbers, ommunity, Subdivision, of No., Parcel, Zip Code)
TOPOGRAPHIC / LAND�.�SETTING:
❑Slope ❑Valley rk t ID Ridge ID Other
(check appropriate box)
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LATITUDE 3 �l „l t
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE S7 6 L) I, i 5-g
Latitude/longitude source: ❑] S ❑Topographic map
(location of well must be sown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME , t✓. P1ak-ke.,iNv)k,._,3nn
ST ET ADDRESS - t, \-1vCNOC
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City or Town State
Zip Code
YES VNO ❑
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Area code - Phone number -
5. WELL DETAILS: ��� ;
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS L FT. Above
Land Surface*
surface may require
2C .0118.
fi )'/.
*Top of casing terminated at/or below land
a variance in accordaftce with 15A NCAC
e. YIELD (grim): AO: METHOD OF TEST
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 9 Q V/
v4 �.� 3
3
f. DISINFECTION: Type-1 Amount /^ / /
g. WATERRV ZONESC(depth):c r
/ From 0- To rP-)From To
From To From To
From To From To
6. CASING: Tk
From i� Dep
Ft. 0��oter W'Y�hicSness/
From To Ft.
From To Ft.
7. GROUT: Depth r i ,D ,gP✓���`�-
Materi I1 Method
From 0 To 3v Ft � �-flryJ
From To Ft.
From To FL - -
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 Material
From To Ft.
From To Ft.
From To . Ft.
10. DRILLING LOG
From
11. REMARKS:
o ' ation Description
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MAY 13 2011
Information Processing Unit
D WOiBOG
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.
SIGNA RE OF CERTIFIED WELL CONTRACTOR DATE
C-Tc)1it) in «)u4
PRINTED NAME 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