396524_Well Construction - GW1_20110802

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # d 345'
1. WELL CONTRACTOR:
nTh: U4. 11i 5
Well Contractor (Individual) Name (�
CY1L‘,Ws VJ 2l l J'rl l
Well Contractor Company Namer, ®�
STREET ADDRESSca` ?J (� &. C"��) \ 1.
c r k-N- N c__ V ,,D �7
ity or Town ate Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
/19 9
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check AA plicable/`Box): Residential Water Suupp
DATE DRILLED / r�,9O-/) KK.d4"au
l
TIME COMPLETED " AO- I I AM El PM (4}-
3. WELL LOCATION: ' ) / n 1
CITY: / 7 /A'n (/i )l/ COUNTY blab
3O ‘
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley kIngr ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3 (-5 a
LONGITUDE 4Q ILO
Latitude/longitude source: r . ❑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
OWNERS NAME U� V\\WVV
STTREEE,TADDRESS �\ C.SnPAI-1\r C
c, T
t U . -\(\) , N a 2) �
City or Town State Zip Code
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Area code - Phone number
May be in degrees,
minutes, seconds or
in a decimal format
5. WELL DETAILS: ''jj /`� s
a. TOTAL DEPTH: '7l� v
b., DOES WELL REPLACE EXISTING WELL? YES 0 NO 1
c. WATER LEVEL Below Top of Casing: AS 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.
V
e. YIELD (gpm): O METHOD OF TEST 4 . R
f. DISINFECTION: Type / j / /7 Amount / 1/:) /
g. WAAR ZONES (depth):
From 7 %. To CJ Q From To
From / bb To 5 From To -
I b
From/ SL" To ( 7 From To
6. CASING: `/ 7gThickness/j1 t��
From 0 DTo �.�G /Ft. �a�P J f; o, c
From To Ft.
From To Ft.
7. GROUT: 2
Depth tt�� aten '� Method
From To 0 Ft. 'Pti/ 0/Lr/e
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From ��To Ft. in. in.
From To Ft. in. in.
From To Ft. in. - in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
TQG I Formation De crip "on
(�J oo(f ...A.,‘ i� P /�d e',v
,I
ck6 ' g. 4V__
VO
40v -
AMIIMILVMMY
RECEIVnY
ALU v 2 /Ufl
Information Processing I 'nit
UWQ/BOG
11. REMARKS:
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. TOn /-
' / r �.L�:CeuJ y-AOv-1
SIGN RE OF CERTIFIED WELL CONTRACTOR DATE
a -An) l'l. P7q?4,'S
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 GVy.-1 a
Rev. 7/05