390550_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION.# vC 63 8
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
�C -1 Li t r
Well Contractor Company Name _ J
STREET ADDRES
C_ A2a7
City or Town State Zip Code
c.‘
Ara code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) ''``
STATE WELL PERMIT#(if applicable) / V r` / dp
2—
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Checkk(Atplicable Box): Residential Water Supply
DATE DRILLED / © 4- J
TIME COMPLETED / --J — J O AM 0 PM f
3. WELL LOCATION:ii,,
ITY: �I4%( Mg COUNTY ail)IOiU
Cx
(Street Name, Numbers, Community, Subdhision, Lot No., Parcel, Zip ode)
TOPOGRAPHIC / LAND SETTING:
(14ope ❑Valley ❑ Flat ❑Ridge ❑Other
(check appropriate box)
LATITUDE ,) 7 • .J :4� L1
LONGITUDE : 6_ L/S OP/
Latitude/longitude source: DGPS ❑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 j/� Cv Vq i(/� /'I'3Ni 1li C�fir�/15Z
i
STREET ADDRESS 't-Ci11 I i' ttth C,'OSSIls/r
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
May be in degrees,
minutes, seconds or
• in a decimal format
61 Le)
b. DOES WELL REPLACE EXISTING WELL? YES 'NO 0
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): aMETHOD OF TEST .n i /C
f. DISINFECTION: Type // t/i
g. WATER ZONES (dee th):
From /'J To 76 From
From i ) To /e () From
Amount Z y/, )
/eSTo J/�)
To
From % Sv To / From To
6. CASING:
Depth__,2 D)'arr er
From C.,To. '1/1 Ft. (.:)
From To Ft.
From To Ft.
Thickness/
W /25 al
7. GROUT: Depth , Mate
rialFrom 0 To AO Ft. /9 eili lire
From To Ft..
From To Ft.
Method
(/ C16f
$ SF omEL , Dept Diar etgr Slot �e In Wee,
(J �V In. r /7 l
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
Size Material
From To Ft.
From To Ft.
10. DRILLING LOG
Frolr, ©s
7' 6' :.Z vu
aou at0
11. REMARKS:
o,Imati De cription,
ed CA ny
0W1) Jii/g4,4
.0 OJI� Nu4?
f,Xye -J- Clu r
/l0')7ii V'/zvoyr
/34
IWED
:;:•:r4 0 7 2011
lnfornsation Processing I Init
DWQ/BOG
I 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.
l Pit r%�� 9'J:4'-i(�
SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
uoiou r1,
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