398257_Well Construction - GW1_20110923

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3242
1. WELL CONTRACTOR:
Larry Tucker
Well Contractor (Individual) Name
Tucker Well & Pump Inc
Well Contractor Company Name
STREET ADDRESS 3150 Centergrove Rd
Kannapolis NC 28083
City or Town State
( 704 )_ 932-3296
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
3. WELL USE (Check Applicable Box): Residential
DATE DRILLED 12/30/2010
Water Supply 0
0 PMO
Union
TIME COMPLETED AM
4. WELL LOCATION:
CITY: Mineral Springs COUNTY
Lot 6 Houston Ridge
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley 0 Flat 11 Ridge 0 Other
(check appropriate box)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source: o GPS o Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. WELL OWNER
OWNER'S NAME
STREET ADDRESS Lot 6 Houston Ridge
Mineral Springs NC
City or Town State
( )-
Zip Code
YES 0 NO 0
FT.
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 700
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 50
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 FT. Above
Land Surface*
surface may require
2C .0118.
TEST blowing
*Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e. YIELD (gpm): 1 METHOD OF
398257
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From 300 To 700 From To
From To From To
From To From To
7. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 110 Ft. 6" plastic•.
From To Ft.
From To Ft.
8. GROUT: Depth. Material Method
From To Ft.
From To Ft.
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
From To Ft.
11. DRILLING LOG
From To Formation Description
0 1 topsoil
1 50 yellnw dirt
50 110 sandrock
110 700 blue rock
1 a r-- f ° K... ,,,,
12. REMARKS: cE,p 2 3 1
11furmaf
11
4.s.,
U ' 'ss
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRCJCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
Larry Tucker 1/22/2011
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Larry Tucker
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. 3/07