390548_Well Construction - GW1_20110107

Well Contractor Compan Name
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # aZG c3 g
1. WELL ONTRACTOR:
r-Ci v-\\i s
Well Contractor (Individual) Name
t� r U s Del \ 1
CS-ic
Street Address
City or Town State Zip Code
Area code Phone number
2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# / j
6 - 5/
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply
7
DATE DRILLED / - / - /O
TIME COMPLETED' 7- 2- /6
4. WELL LOCATION:
CITY: / 10/u b E'
AM❑ PMt13---
COUNTY 11Nt v/U
\LCAn3 Cb)ee1
(Street Name, Numbers, munity, Su ivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Valley lat ❑Riddge ❑Other
LATITUDE Q 47 ` ° 5XXX 5' AO " DMS OR 3X.XXXXXX DD
LONGITUDE 08� 310 ' d 9% " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: , [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Owner Name
Address
9 ► IQ
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 306
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO LY
c. WATER LEVEL Below Top of Casing: e2 0 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 7 ,� METHOD OF TEST ,4
f
f. DISINFECTION: Type //7?4.7 %19 Amount .2 '
9
g. WATER ZONES (depth):
Top /45 Bottom /25- Top Bottom
Top cX 26 Bottom vq 7 ? Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth
,Top 0 Bottom
Dia eter Weight aterial
////
7Y Ft. �`57 • /15_ Uc
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Q Material Method
Top O Bottom JC E Ft. R7a/6,V'e
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
® / 026`
30'
/ /60
F ionse /'vn
60 /aGO ji7/Vf
a0O / 3OG'
/
12. REMARKS:
J4me
—RECEIVED
J N 07 2011
information Processing Unit
D W Q!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.
SIG TURE OF CERTIFIED ELL CONTRACTOR DATE
7-
jbAtu ('1, r?ukk;S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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