398426_Well Construction - GW1_20110930

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-. Division of Water Quality
WELL CONTRACTOR CERTIFICATION # .3002-A
1. WELL CONTRACTOR: •
f114 Moe L.Ou0CR-
WeII Contractor (Individual) Name
CARo14Na 0E44- D9-11.41.46
Well Contractor Company Name ,y� /J
STREET ADDRESS 66/11( /! /E1st.iAi A.
r "0N120E A/c 28i/2
City or Town State
( 1o1 )_ 76;41-808'5-
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(inapplicable)
DWQ or OTHER PERMIT #(if applicable) /D -/S8
WELL USE (Check Applicable Box): Residential
DATE DRILLED 2.- /'/ - l I f r
Water Supply 0
6A770,-, O^'t`r
❑ PM p'
1.1N16-4
TIME COMPLETED 5:00 AM
3. WELL LOCATION:
CITY: (.-47c{lp44 COUNTY
S-rRAr-R N ° A., ()Aprce L7-7-- # 20
(Street -Name, Numbers, Community; Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley p'Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3 g v A?.3r0N
May be in degreeso
minutes, seconds or
in a decimal format
LONGITUDE g O '' l/S: SSW
Latitude/longitude source: La'GPS ❑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
OWNER'S NAME / ci-SuSA+a I1012NI
STREET ADDRESS 5021 t,../list/,(tr A.
(..), 04,4vv .mac 28173
City or Town State
( 2o/ )- 35fe- 656
Zip Code
YES 0 NO pY
35 FT.
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 905
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS / . FT. Above
Land Surface'
surface may require
2C .0118.
Abe.
'Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e. YIELD (gpm): 17 METHOD OF TEST
Amount
39842
f. DISINFECTION: Type -70°I /.}ny
g. WATER ZONES (depth):
From /2 3 To From To
From 2 / S To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 63 Ft. Lo /R " 532L1 eve.
From To Ft.
From To Ft.
7. GROUT: Depth Material . Method
From D To 35//
+ Ft. 0?E,,7v..,re Pwe+P
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
From To Formation Description
o ) 5 Drar
I 5rf .B90-4r 17ia.-
51f 905 Ga4wl7t=
11. REMARKS:
ao" cam+ art rd s7a"
.�l-,
d --
SEP 3 0 2011
Information Processing unit
DVVUltil,»
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.
2-Zo-11
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
IL16 L.. OLlvtif- Cam,. D. /14c rrey
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-la
Rev. 7/05