GW1--02872_Well Construction - GW1_20240510

0� d RESIDENTIAL WELL CONSTRUCTION RECORD
-.4Vri; - - ` ' North Carolina Department of Environment and Natural Resources-Division!
[[[ision of Water Quality
•`Vim -1'. ��
�' WELL CONTRACTOR CERTIFICATION#
1.WELpiNTRACTOR: ` f. DISINFECTION:Type r / Amount. �� If U�f1
?/� 4- . �(' I a PP g. WATER ZONES(deprtthh):
Wet Contractor dividual)Name / /C� // 9 From 3 30 To 33 f From To
Q 44, et Li/3' C()e ( ,br't/4�P�{ From To ! From To
Well Contractor Company Name J From To From To
STREET ADDRESS /53 773 CLci 3 G sI-A h'e 7. CASING: Thickness/
t /' n Depth Iar� ter ��e�ht Ma ri�
( ice' lT-.r"T 3 O C F( From c Depth
.Ft. 1 �y !a( o?
City or Tow State Zip Code From To Ft. /
7O/')- 7 Q a ^ 37 gA. From To Ft.
Area code- Phone number
8. GROUT: Depth atenal Method •
2.WELL INFORMATION: ED To. © Ft. 0 6 & es-)to
From
SITE WELL ID#(if applicable) - - From To Ft.
WELL CONSTRUCTION PERMIT# From To Ft.
OTHER ASSOCIATED PERMIT#(if applicable) S
9. SCREEN: Depth '` Diame er uiot Size Material
3.WELL USE(Check Applicable Box): -RResidential Water Supply 0 , From To Ft. in. in.
DATE DRILLED f al, . 021 From To Ft. in. in.
TIME COMPLETED t_ t7I AM0 -M0
From To FL in. in.
4.WELL LOCATION: d p 10.SAND/GRAVEL PACK:
SCO./J -004-G'. COUNTY M ets!0i1 Depth Size Material
CITY: l From To Ft.
/�� / /� e�cJ,, Rd i From To Ft.
(Street Na e,Numbers,Community,Sdbdivision,Lot No.,Parcel,Tap Code) From To Ft_
TOPOG- /LAND SETTING:
0 Slope a ' - 0 Flat 0 Ridge a Other 11.DRILLING LOG
( propriate box) Formation Descri tion
May be in degrees, From To p
LATITUDE _ minutes,seconds or ,� 5�, y ,, e���
LONGITUDE in a decimal format
Latitude/longitude source: a GPS a Topographic map '3 5 ^ L/ 4 r
(location of well must be shown on a USGS topo map and • I
attached to this form if not using GPS) 3 7 -
5.WELL OWNER ^ I I ,�-• ...
yi law�e ...C"'
ti= .
OWNER'S NAME f C_K, �uL�
STREET ADDRESS (0 0 41'(a(- 12 c�t R MAY 1
S-6! l M z /Uc '. ? 7 s_
City or
State dip Code ,, .,w
. 70; ).- L 9a - .23C�
Area code- Phone number 12 er¢Rli9, y,,
6.WELL DETAILS: �7
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES a 00 100 HEREBY C - FY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
F`� 15A NCCONSTRUCTION ST•NDARDS,AND THAT A COPY OF THIS
C. WATER LEVEL Below Top of Casing: (� v FT. RECO'% N PROVI D TO T �„
(Use"+"if Above/Top of Casing)
, ' // �
d. TOP OF CASING IS l FT.Above Land Surface'
4 .62y.
SIGN OF CERTIFIED WELL CONTRACTOR DATE
'Top of casing terminated at/or below land surface may require � /' .
a variance in(a ordance with 15A NCAC 2C.01118. © y. /�/f`��(
e. YIELD(gpm): ( METHOD OF TEST /�� f V PR N Er AME OF PERSON CONSTRUCTING THE WALL
LJ °� 30, ,, S , 4 N
C
Submit the original to the Division of Water Quality within 30 days. Attn:Information Mgt., Form GW-la
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext1568. Rev.3/07