390567_Well Construction - GW1_20110107

WELL CONTRACTOR CERTIFICATION #
1. WELLCONTRACTOR:
Jahn Ulf
ell Contractor (Individual) Nam
L MU (1.
Well Contractor Company Name L J
STREET ADDRESS �'(r Sc 141I 1. I�C.I•
Cyurlo. NU�3
CI or Town State Zip Code
)-
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) /
STATE WELL PERMIT#(if applicable) /6 0��7
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply IV
DATE DRILLED i Q� oZ3- J O
TIME COMPLETED S i U. AM ❑ PM [/
3. WELL LOCATION:
CITY: m 0 NRo e COUNTY UN;O ✓V
46 23 1/0)-111 JToile Rd
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
IDj
Slope ❑ Valley ❑ Flat (ITI!dge ❑ Other
(check appropriate box)
LATITUDE 3 c) �r 1157
/'9
LONGITUDE I _a r (o7!�
Latitude/longitude source: ['PPS ❑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 n
OWNER'S NAME f ry� 1 ii �j elk) 1-./ 0 (1)e
STREET ADDRESS Li ,23 WNr'/e S%Re /Z(�
� e
May be in degrees,
minutes, seconds or
• in a decimal format
(,cJ; IN t7'e /Il269/ 7 g
City or1 own State Zip Code
G? 9- a oi
Area code - Phone number
5. WELL DETAILS: r r
a. TOTAL DEPTH: 3 'IS
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Filfi
3
c. WATER LEVEL Below Top of Casing: 5 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in Apcordance with 15A NCAC 2C .0118.
e. YIELD (gpm): _ _ METHOD OF TEST A
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
ao3?
� rZ 73 �56
f. DISINFECTION: Type_97/7
g. WATER ZONES (depth):,
Amount o2-/'a/UL
From 96 To [s From To
From To From To
From To From To •
6. CASING:
Depth a Diar}leter
From 0 To S.Z Ft. (9 T$
From To Ft.
From
To Ft.
Thickness/ Weight
gt ya r
7. GROUT:
Depth qq `r aten • t_
From 0 To �) J Ft. eN o1 e
From To Ft.'
From To Ft.
8. SCREEN: Depth Diameter Slot Size
From To Ft. in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From
Size
To Ft.
From To Ft.
From To Ft.
Method
in.
in.
in.
Material
Material
10. DRILLING LOG
Fom�o
Formation De rip ion
P�1�JJ
36 ,5'O
< -o /ao' e s 4
JO V 3 /S' /"Y7
11. REMARKS:
RECEIVED
2011
Information Processing 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.
Ar'23-10 .
SIGNkTURE OF CERTIFIED WELL uONTRACTOR DATE
3aLv rf, mu)Ws
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-la
Rev. 7/05