390554_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ! 0 32
1. WELL CONTRACTOR:
Well Contractor (Indbriduap ame
VIM Contractor Company NameNaam
S ET ADDRESS((1k�{ �co u tv
G( I l l P
J OLv- Oj k Mc„ t,?RQ7
(Ay or Mpg Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL FERMIT#pf applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check ApplicablenBox): Residential Water Supply 0
e
DATE DRILLED i ' 1 -i 0
4'
TIME COMPLETED . Cc) AM ❑ PM
3. WELL LOCATION: 8 J�
CITY: M Irk COUNTY .�i t � n
(Street Name, Numbers, Conimunity, Subdivision, Lot No., P eI, Tip Code)
TOPOGRAPHIC / LAND SETT .
❑ Slope O Valley ❑ Flat idge 0 Other
(check appropriate box)
LATITUDE 3 c 7 rr. & / (a
LONGITUDE _S° 2 +Pt7'
Latitude/longitude source: a 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
OWNER'S NAME �r�c d i ri M Q c
STREET ADDRESS J f f tiatN
Cityorr own State Zip Code
'a.q I tP
Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS:
O
a. TOTAL DEPTH: U
b. DOES WELL REPLACE EXISTING WELL? (Y-ES NO IDc. WATER LEVEL Below Top of Casing: L J 3 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): 7 METHOD OF TEST
3
f. DISINFECTION: Type 1-4" i fi-- Amount i
pi-
/�
g. WATER ZONES (depth):
From / 3 0 To 5 From To
From / 7 0 To / PO From To
From o2-Z 0 To 3 6 Q From To
6. CASING: a)r}et Thicgkneess/ �aje�t
From D Depth
To /� Ft. P4 v/ /-J r UrQ
From To Ft.
From To Ft.
7. GROUT:nal Depth , ate , ��MMeethhood
0
From To 3� Ft. Pail, /re 02ged
7��
• 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 Formati n Description
96 ec N
'
V 80 '1 Rawl) A '/ CLely
goy /a 6 D4 BIC/ e
704m)
rq0 ' .266' /awn) v4g, z/e,�.1%
�Ov 4160 ` .<yP 31.147
RECEIVED
11. REMARKS: `i..N 0 7 2011
tnrormauon rrot essi1 y Ul1it
nwrl/R(X,
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.
fh /7e&, /6 ' I /d
SIG URE OF CERTIFIED WELL CONTRACTOR DATE
jv),n, r1/ MC,44:S
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-1a
Rev. 7/05