390555_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # t? Q
1. WELL CONTRACTOR:
Irt n m u ll I`s
Well Contractor (Individual) Name
MVa k 1)` � J3 snit ►`�9
Well Contractor Company Name
STREET ADDRESS Claw �U C.i . 4I t Rci
City or Town State Zip Code
?0��)-� 5694.
Area code- Phone number
2. WELL INFORMATION: Q
SITE WELL ID #(if applicable) /� / t ) "2 C O
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supp
DATE DRILLED /U 09—%® VVV
TIME COMPLETED/6 -2 /- « AM ❑ PNat
3. WELL L CATtON: 1,
CITY: S 1) .3�-ram COUNTY Lth JcC�►ri
O,ct. Ike. t r�cc� -ECN 4
(Street Name, Numbers, Commun' ubdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley L 0 Ridge 0 Other
(check appropriate box)
LATITUDE
LONGITUDE
Latitude/longitude source: S ❑Topographic map
(location of well must be s own on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME ,�,�� J ('L 1 c.,
STREET ADDRESS Jr�L(�ll'. a La T
STREET,
t� NG
City or T State
o :� a I�u�G 1
May be in degrees,
minutes, seconds or
• in a decimal format
�
Area code - Phone number
5. WELL DETAILS: el U
a. TOTAL DEPTH:
errs .LJEani-
agnq
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 30 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):ts METHOD OF TEST Air
C
f. DISINFECTION: Type 1 r*— Amount P-4-Tt-}-
g. WATER ZONES (depth):
From iS 0 To ..5. From To
From To From To
From To From To
6. CASING: Thickness/
Depth 4 D)art� er Wei gt` fmr{al
From () To Y) Ft. (D /S� / I2W /�' U L
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0 To 35 Ft.getb iU.T
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.
From To Ft.
From To Ft.
10. DRILLING LOG
From, To ,
0 /o
11. REMARKS:
• ati n D. erip 'on
.OWIMEMISL
.r1
RECEIVED
AI 07 2
information Processing Unit
DW Q/tiOG
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 26, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
zt A4' o-za-to
SI URE OF CERTIFIED WEL CONTRACTOR DATE
Mu11115
PRINTED NAM 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