390551_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # A 0 3
1. WELL CONTRACTOR:
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Well Contractor (Individual) Name
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Contractor Companya�Name ` .
STREET ADDRESS CI-) l^� ` x ATRLC . `
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City or Town State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) ^
STATE WELL PERMIT#(if applicable) ( I (CIO
DWQ or. OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED C\ I
TIME COMPLETED, C AM ❑ PMp
3. WELL LOCATIONS
CITY: ,f ,T< 1"4' 'tx 5 COUNTY V-- ror\
a,C711 k IA16a
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTIN
0 Slope ❑ Valley ❑ Flat . dge 0 Other
(check appropriate box)
LATITUDE 0'' 3 ‘'7 ^I \
`- LONGITUDE _ 1 l , of / I
Latitude/longitude source: b2r4S ❑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,` \1 `tv> \ i
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS'
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City or Town State
( )= q 0�— � �1 17
Area code - Phone number
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Zip Code
5. WELL DETAILS: �'��
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 Nt
c. WATER LEVEL Below Top of Casing: 31 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): ,'v METHOD OF TEST cX.\ C
f. DISINFECTION: Type 1--k 7ii\ Amount (�
g. WATER ZONES (de%th)): 11
From /9� To //V b From To
From / 6 To / ( 3 t' From To
From To From To
6. CASING: /j jar��,r
tg
From 0 Depth,
Ft. /o %X
From To Ft.
From To Ft.
Thickness/
W�ight� ryFe;erjalI,
o
7. GROUT: , Depth /�Materiiall ,^� Methods, _ f
From () To (.3 Ft. Nrt NfO/bt/C r:;4l
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
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11. REMARKS:
F.rmation Desciption
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RECEIVED
_I AN 0 7 2011
information Processing Uiri
D`P)C.BOr
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.
SIG URE OF CERTIFIED WELL CONTRACTOR DATE
JO), n) (''1. Y ) 1,1\- 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-la
Rev. 7/05