396523_Well Construction - GW1_20110802

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # dl Q
1. W ONTRACTOR:
n Muttii:
ell Contractor (Individual) Name
V (�I(Yl(I (f 1)\et 1 vi /.10\
ell Contractor Company Name
STREET ADDRESSCW ffW j r' C d 1(� ` g,I
off.. M a oI7
State Zip Code
44)- t_.-qc_.,cs(nel 4
City or Town
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(i( applicable) /�
STATE WELL PERMIT#(if applicable) // V ~ a,
DWQ or OTHER PERMIT #('1f applicable)
WELL USE (Check Applicable Box):. Residential Water Supply I
DATE DRILLED 7- ) y- / /
r/
TIME COMPLETED / ' 2 /� 1 1 AM D PM [§�
3. WELL LOCATION:
CITY: / )13R 0 e COUNTY
9JI i ..S/ Rocky Rio
(Street Name, Numbers, Community, Su ioision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box,y�
LATITUDE 3 -7 r7, 12
LONGITUDE � 17 3 7,
Latitude/longitude source: effdPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
May be in degrees,
minutes, seconds or
• in a decimal format
4. WELL OWNER
OWNER'S NAME /
STREET ADDRESS 7 / Rvf e l'
(1J / /6
State Zip Code
riorugwe
City or Town
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
yid
A25
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use "+° if Above T%off 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): METHOD OF TEST ti /R
0
�YES Cji NO 14
LS FT.
3;;,., r rj•
j 7—/� �
f. DISINFECTION: Type /T / %J Amount
g. WATER ZONES (depth):
From 7 5 To From To -.
From / 33 To / 0-S From To •
From / �.S To / ?O From To
6. CASING: Thickness/
Depth /, � D}'a�gj�r Wei ht N�t�Qal,.,
From To /Y Ft. /p/jam , �� 1' (J, c
From To Ft.
From To Ft.
7. GROUT: Depth o Mate ' Method
From 0 To 35 Ft.17 e/il CN+T� li/�i
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
ioFi 0 ,
•
11. REMARKS:
orm.tion,,Dssc iption
AUG 0 2 2011
information Prod,sing Unit
DWQ/DOG
1 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.
(2-). r 11
SIG TURF OF CERTIFIED ELL' CONTRACTOR DATE
064 rt>. /, me/AO
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