390560_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
, WELL CONTRACTOR CERTIFICATION # 9.0 3
1. WELL CONTRACTOR:
Well Contractor (Indivi ual) Name
l 11"1u1‘1's NI i)II'i��c
ell Contractor Company Name
STRE T ADDRESCCif C4 r - �tl 1 Pd
City or Town t Zip Code
Area code- Phone number
2. WELL INFORMATION: l Q
SITE WELL ID #(if applicable) / (//'�� )' Cam. ) U
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable
Box : Residential Water Supply ❑
DATE DRILLED I 1 -.1 {'Fu
TIME COMPLETED , CO AM 0 PM is
3. WELL L CATTION•t �^
CITY: \P�L�tJA0.� V\ (� COUNTY
(Street Name, Numbers, Commur ,, SubdNision, Lot No., Parcel%p Code)
TOPOGRAP IC / LAND SETTING:
0 Slope alley 0 Flat 0 Ridge 0 Other
(check appropriate box) LATITUDE 3 s� // 7 5 p
LONGITUDE 80 3 ' 3 J
Latitude/longitude source: y 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
OWNER'S NAMEC k S I G
i I1
STREET ADDRESS (C)\
Cityor Town
ELK7- 9. g)
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
State
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO IV'
c. WATER LEVEL Below Top of Casing: 36 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): 1 6 METHOD OF TEST fi tin
3
f. DISINFECTION: Type A/7W Amount A iryi)
g. WATER ZONES (depth):
From o.7rTo A PS From To
From To From To
From To From To
6. CASING: Thickness/
Depth D))'ameter W igh�. I
From 0 S Toil) Ft. £ 7R '
From To Ft.
From To Ft.
7. GROUT: Depth , pMaterj , Method
From 0 To 6 ,L7 6 Ft. PN�O/L�fe
From To Ft:
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 Size Material
From To Ft.
To Ft.
To Ft.
From
From
10. DRILLING LOG
F5m 3o6
/a' au'
f9,(X) a 5e5'
11. REMARKS:
Formation Description
allme
D
.N 07 2011
Infnrrnaririn Processing Unit
DWQ/BOG
. 1 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.
�p (441,'5 //—a2 /O
SIGN RE OF CERTIFIED WELL CONTRACTOR DATE
TO )1 ri r1. rioz1,5
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