396530_Well Construction - GW1_20110802

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qiiality
WELL CONTRACTOR CERTIFICATION #
1. WELL QNTRACTOR:
Well Contractor (Individual) Name
rnv,kV5 C (1ltw3
Well Contractor Company�Name
STREET ADDRESS (— It) co 8 ,i F-Pc l)1 1 Pd
(Qaa r7
City or Town State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
//- 3 3
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check �`Applicable Box): Residential Water Supply 0
DATE DRILLED S -_2 �)/ —/ // j
'TIME COMPLETEDL ' /! O�5- AM 0 PM [ �
3. WELL L/OCATION•N�I•
/ /J�
CITY: W C'Lf a/L J /V %I! COUNTY (,/ , /v/IQ 1 ytV
V1CieJl
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zp Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑Valley clieraT ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3 ,l `). /% 2 J2
LONGITUDE 7' CS Y /+ [
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑ ❑ Topographic map
(location of well must be own on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME L-O(. U1 S ?Oa.
ST ET ADDRESS/)' m t"* (J` h).
)a�hac N ;y )7 3
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS: 7 ` (�
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L�
c. WATER LEVEL Below Top of Casing:
(Use "+' if Above To 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 / /8.I rlc
J 6 FT.
f. DISINFECTION: Type ! / t/ /
g. WATER ZONES (de th):
From / i:J 5 To /�
From To 1 ?.
From " ) To l
6. CASING:
/
From v Depth,
From / Ft. / toaJr�y}e�er
Ft.
From To
From To
Ft.
Amount . — PT
From U5To0U6
From To
From To
Thickness/ 1✓L t�t�q
t
7. GROUT: Depth Materi .�r•
�
From To ao Ft. 67e/Wartiite
From To Ft. •
From To Ft.
8. SCREEN: Depth
From 30
From To
From To
Diameter Slot Size
Ft. in.
Ft. in.
Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From To
6
11. REMARKS:
in.
in.
in.
Material
Material
rmatipn D- ciption
RECEIVED
AUG 0 2 ;dill
mdtiur: ,,:essing Unit
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.
SIGN RE OF C RTIFIED WEL CONTRACTOR DATE
SO A ,1; !''"). /144 :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 GW-1a
Rev. 7/05