Loading...
HomeMy WebLinkAbout390554_Well Construction - GW1_20110107RESIDENTIAL 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. (919) 733-7015 ext 568. Form GW-1a Rev. 7/05