HomeMy WebLinkAboutWELL-11-09-2528.TIF
CDP File Number: 35937 County ID Number: E"PR-10-09-2374
Drawing Type: Construction Authorization Date: 1 1/ 0 6 a 0 0 9
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a ysrn7£,' RECEIVED
RESIDENTIAL WELL coxslTtuCnON RECORD
2009
North Carolina Department of Environment and Natural Resources- Division of Water Quality
CATAWBA COUNTY
WELL CONTRACTOR CERTIFICATION # A
ENViRONIMENTA! FiEAl.TN
1. ILL CONTRAC~T~OR: Top WATER
-°7D Bottom (depth): Top Bottom
t'`t•LSS~ I I
R ;L 5 e_ j j (individual)
L~ e_I, Name J)r` I t rll N tL Top Bottom Top Bottom
Well Contractor Company Name Thickness/
I t
~ ~ b e r f y L. h a 11 'R e )ad 7. CASING: Depth Demeter Weight Material
Street Address Topes _ Bottom G/ Ft. 12, S D le., I P l/ C f-
av I i) rs J L' N Top Bottom Ft
Co or Town State Zip Code Top Bottom Ft.
Area code Phone number 8. GROUT: Depth Material Method n
2. WELL INFORMATION: = Topp_ Bottom_ Ft --f
WELL CONSTRUCTION PERMIT# W/ S Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID #(if applicable) 9. SCREEN: Depth Diameter Slot Size Material
3. WELL USE (Check Applicable Box): Residential Water Supply Oro' Top Bottom Ft. in. In.
DATE DRILLED Top Bottom Ft in. in.
Top Bottom Ft. in. in.
TIME COMPLETED / 3 D AM 0 PM COY'
4 WELL LOCATION: 1o. sANDfGRAVEL PACK:
Depth Size Material
CITY: ( ~[~/LC'. rrt L COUNTY Top Bottom Ft
fey~ Top Bottom Ft
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel. Zip Code) Top Bofom Ft
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 36 DMS OR 3X.XXXXXXXXX DD C/
LONGITUDE 75/Ll1)Q(ff/ DMS OR 7X.X XXXX CXX DD
Latitudellongitude source: EPS . Cropographic map /
(location of well must be shown on a USGS topo map andaffached to /
this form if not using GPS) l
5. WELL OWNER /
Owner Na 2= /
c5
Street Address
/L~iryt.rJ n l / L C __2
City or Town State Tip Code /
Area code Phone number 12. REMARKS:
6. WELL DETAILS:
a. TOTAL DEPTH: c~~s
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO COY' i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below.Top of Casing: r~ FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
: PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS FT. Above Land Surface` ;
*Top of casing terminated atfor below land surface may require 'e e-7
a variance in accordance with 15A NCAC 2C.0118. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD (gpm):_ METHOD OF TEST VjJ u 5e-
I. DISINFECTION: Type 1 r N Amount PRINTS NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GWAa
+0+'7 ae..a c.....:.... n.+..~e. OainGnM IJ/` 97ROQ_IQ4 Dhnno - /9191 Rn7_A1r1n Rev. 2/09