398420_Well Construction - GW1_20110930

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-, Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
+?Atav- e L. Wye*.
Well Contractor (Individual) Name
CARouhiA WE t 1. DCLAu.trAG
Well Contractor Company Name D_
STREET ADDRESS' (o(.I4 ME A,. M•
moopc pc- 2.$112.
City or Town State
( 704 )- 1 bN- $0$5
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable) //"• / 5
WELL USE (Check Applicable Box): Residential
DATE DRILLED 9-12-11 11204600040
Water Supply ❑
NQNL,y
❑ PM ait/
u4l04
TIME COMPLETED '/:00 AM
3. WELL LOCATION: •
CITY: i tM101.4W COUNTY
lPOVIDEtJCE Do NsIS Ur * Ott
(Street -Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley I!lat ❑ Ridge ❑ Other
(check appropriate box)
3 J5 ° DO. Og3
May be is
degreLATITUDE
minutes, secondsconds or
in a decimal format
LONGITUDE.__ll Q° 0. 553
Latitude/longitude source: IMPS Li 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 Dp -
OWNER'S NAME SCc5rr i"ogt,4sON
STREET ADDRESS Il402, Ci gemii.t.. y�cw,+S Dt-
I.JAKt14w Je. 2t t) 3
City or Town' State
( 7ov )- 2N3 - 0390
Zip Code
YES ❑ NO re
21 FT.
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: . 580
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.
AA
'Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e. YIELD (gpm): 25 METHOD OF TEST
3ooz A
398420
f. DISINFECTION: Type 1o% kV/ Amount 30 0Z.
g. WATER ZONES (depth):
From 305 To From 5.70 To
' From 5-.2O To From To
From S(or To From To
6. CASING: Thickness/
Depth Diameter Weight M terial
From 0 To /55 Ft. &'/s" stay Pve
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 204- Ft. BFNTON i7E Rime
'From To Ft.
From • To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
Froni 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 F• rmation Description
0 7 r L • i.i ^SRr
1 38 '._•w.+ C
38 8s th•frx Ear
85 /3C : • •w+ . . G v c
/35 580 ; pin*
r--ihP�rr1....RIP
11. REMARKS: CF P 3 ('i 2011
t.,f.,rmation Processing Uni
DWQ/BO'
I D0 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.
i $1 /. �G/ 9- 20-,r
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
'MA rn If L. OLWER-
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