390543_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
(7263,8
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR
Well Contractor (Individual) Name
ell Contractor Company Name
Aao,c)...k,---vc-Ica_. \ Pci,
S r et Address
�1 7
City or Town r J State Zip Code
(xxL �� 5 (fiz-j
Area 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
(P Ly�
DATE DRILLED - a -/ - / b
� 0 H TIME COMPLETED' ld AM ❑ PM$
CITY: t`il%%i)(/// ) COUNTY V1 NI Uil%
2Gok;,x1.d5.3
4 4
(Street Name, mbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑i Slope Valley rlat El Ridge ❑Other
LATITUDE 63 7'J/ / 6 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE DO O ` /Zk.57 _ ' - " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: [ 3F Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) ,
4. WELL LOCATION:
5. WEL WNER
leer ame
13 I W
Street Address
City or Town State Zip Code
(4'4) 3( 3- G3
Area code Phone number
6. WELL DETAILS: X o
a. TOTAL DEPTH: V
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ck'
c. WATER LEVEL Below Top of Casing: 3 0 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): Z METHOD OF TEST /-/ ► iZ/y�
f. DISINFECTION: Type f• 77,t Amount
Top
Top
Top
g. WATER ZONES (depth).
Top ,5 Bottom /h b
Top 76 Bottom / 5
Top /9 0 Bottom
7. CASING: Depth / Diameter
Top 0 Bottom U/ / Ft. 6 1/p
Top Bottom Ft.
Top Bottom Ft.
rs
ritt ti
Top Bottom
Top Bottom
Top Bottom
Thickness/
Weight aterial
// Roc
8. GROUT: Depth Material 7-
Top 0 Bottom a 0 Ft. 8 e1u 7�/ �'
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top Bottom
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth Size Material
Bottom Ft.
Bottom Ft.
Bottom Ft.
Method �%
Pe//%O�sC,T
Diameter Slot Size Material
Ft.
Ft.
Ft.
in.
in.
in.
in.
in.
in.
11. DRILLING LOG
Top Bottom
0 %. a 5
.3S`
/ y
/ Svc
i601 -26o
320
/
/
/
/
12. REMARKS:
Fpeaflpn D/✓r AT
L
UGv/U cS%Aie
� vn e
e/4e4OL--a*-
° C IVED
`i.: i �\4 0 7 2011
Information Processing Unit
D'wn/Boc
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.
SIGNititY) URE OF CERTIFIED WELL CONTRACTOR DATE
Jot,n) Y), P2CI4I;5
PRINTED NAME OF PERSON C NSTRUCTING THE WELL
(0-36—
•