390545_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # rQ G,3 O
J �eW4-, CONTRACTOR:
x�`dl mcit(1S
Well Contractor (Individual) Name
t S � rhl tl 1n13
ell Contractor Company ame
Street Address
C" Tows �, J q State Zip Code
Are code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED ( 2 2_ - / G
TIME COMPLETED'6— 2 3 / O. AM ❑ PM 0(
4. WELL LOCATION:
CITY: fAI' U1 tU COUNTY LI/9/iO yt)
l BC1l `Stet
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOP GRAPHIC / LAND SETTING: (check appropriate box)
lope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36 35 ° (7' �//�.�� " DMS OR 3X.xxxxx 00XX DD
O
LONGITUDE 75 °) OOa " DMS OR 7X.XXXXX0XXX DD
Latitude/longitude source: [j 'ISS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. L OWNER
Owner Name
i vc Lome,
St t Addre s
City of Town State Zip Code
(( apc�1 `t ^ •
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: V 2 O
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L�
c. WATER LEVEL Below Top of Casing:
(Use ..+° if Above Top of Casing)
d. TOP OF CASING IS / FT. Above Land Surface*
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): c 1METHJOD OF TEST ft/
f. DISINFECTION: Type /� %/ Amount
35 Fr-
g. WATER ZONES (de th)�:
Top 3/0 Bottom Ji`. Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth , ,Diameter Weight
Top 0 Bottom 35' Ft. 4 1✓�
Top Bottom Ft.
Top Bottom Ft.
Material
Re,C
8. GROUT: Depth Material Method
Top 0 Bottom . o Ft. /3 iii TYLok &/27/0611
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
in.
in.
in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Tom / BQttprp
ao/�3o
/ 9S'
3,5- ' I /O O'
/6 6 / .:2Go
/
/
in.
in.
in.
Material
Size Material
RECEIVED
12. REMARKS:
,,formation Processing Unit
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.
,3/a
SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
cTobv in , r u.4. S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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