390537_Well Construction - GW1_20110107

RESIDENTIAL WELL CONSTRUCTION RECORD,
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 02 0 3 3
1. IlySLL.CONTRACTOR:
Well Contractor ((II�ndividual)
ctName
elI Contractor Company Name
Str et Address
C klC-
ity or Town
oq £ 5- 5C 9y
I i`Nc( ajqr✓
State Zip Code
Area code Phone number
2. WELL INFORMATION: rr�
WELL CONSTRUCTION PERMIT# t V" 40
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 'S -- O - ni
TIME COMPLETED b i 03 AM 0 PM
4. WELL LOCATION:
CITY: sI\C'E i Q r'l L VG_; \ COUNTY J. rA l lW 1
Yl e- -- j t Lr ) 7) .
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND ETTING: (check appropriate box)
❑ Slope ❑ Valley lat ❑ Ridge ❑ Other
LATITUDE • 3 / i g 7 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE Orb ^ , /Q, o - 3 3 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 62r1 (]Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER 11.
- oi 6 • IC-) 5\Aeo-r •
J,uvnpr Name
C° 73"-i7 4-1-\,,i-.. s, ,..if:n a al r . i-R),e,
. :
Street Ad ress
Na.�i�-�-I-N
City or Town1 e'
Area code Phone number
6. WELL DETAILS: /,
a. TOTAL DEPTH: 9O01
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 N
c. WATER LEVEL Below Top of Casing: /5
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 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): / METHOD OF TEST 3- ('
FT.
f. DISINFECTION: Type VA. ( 1-k Amount \
Ciehmif uri+kin 411 ri7vc of nmmmln4inn +n• rlivicinn of W.5+o. _
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top MO -Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
Top t Bottom 7 / , Ft. f
Top Bottom Ft.
Top Bottom Ft.
Thickness/
Weight aterial
/.25 , U, C
8. GROUT: Depth Mater' 1 _L
n
Top 0 Bottom 3 Ft. ,[� e4L 2//(J
Top Bottom 'Ft.
Top Bottom Ft.
Method
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
in. in.
in. in.
in. in.
11. DRILLING LOG
To Bottom/
�
ao
- O / 3G '
/ V r
S// / ,? 6 O
any/ y6o°
/
/
/
/
12. REMARKS:
Size Material
cncr n e jKe&v
4 Le
c4Arr7e
cs'f9% ') e
84,o 5,�ALA,
RECEIVED
0 7 2011
information Processing Unit
U WQ/t3OG
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.
ATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OFPERSON CONSTRUCTING THE WELL
I wifek•n..,f:..n D. e•