HomeMy WebLinkAboutWELL-11-10-12575.TIF f E RECEIVE D
, RESIDENTIAL WELL CONSTRUCTION RECORD FEB 02 2011
" North Carolina Department of Environment and Natural Resources- Division of Water Quality , CATAWBA COUNTY
WELL CONTRACTOR CERTIFICATION # 3 3 O� ENVIRONMENTAL HEALTH
1. WELL CONTRACTOR: • f. DISINFECTION: Type - Ft Amount - .Iryr
.n, ; n ae\ \/\) , �' -aL,L, g. WATER ZONES (depth):
W Contractor (Individual) Name From 4/ (75 9 From To
(A CA) Ot-f e--Ci \i e, t, Z D y--1 \‚ I f 19 From _ To From To
Well Contractor Company Name From To From To
D
STREET ADDRESS a a a\ 1 i I Cflf) R C*cL 6. CASING: Thickness/
A ` I Depth Diameter Wight aterial
is , h CQ.(I VJ C>._ N\ C. r ' (oO 9 From U To A() j Ft. ( j � 1
City or Town Stag Zip Code From To Ft. _ CT
(a7. ,4 ' _L(300 From To Ft.
Area code- Phone number
7. GROUT: Depth Material Method
2. WELL INFORMATION: �. /)
/ / j� ' -) ✓ / ` From v O�
To 9,..42 Ft. �L'Jr _N-1{'_ ?c-,.....rr�
SITE WELL ID *lit applicable) G� / U From To Ft.
STATE WELL PERMIT#(if applicable) From To Ft.
DWQ or OTHER PERMIT #(f applicable) 8. SCREEN: Depth Diameter Slot Size Material
From To Ft in, in.
12}/ WELL USE (Check Applicable Box): Residential Water Supply
/ / From To FL in. in.
/
DATE DRILLED o2 — 6 — From To Ft. in. in.
TIME COMPLETED c ; 3,e) AM D PM p
9. SANG /GRAVEL PACK:
3. WELL LOOCIN: ) Depth Size Material
CITY: i e-A. COON „ From To Ft
From To Ft.
L /.5 - 7; ) 6a1- -k) A D From To Ft.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) -
TOPOGRAPHIC / LAND ING: 10. DRILLING LOG
D Slope D Valley at D Ridge D Other From To Formation Descj 1ption
(check appropriate box) [) / � May be in kfegrees i -7r"'
LATITUDE 3 D 7 ./ minutes, seconds or '��- Ao .1--
LONGITUDE If g!' in a decimal format e V =Arn
Latitude/longitude source: PS DTopographic map 20:::::: , Y `
(location of well must be shown on a USGS topo map and el- $ Gar-
attached to this form 'not using GPS) AL_
4. WELL OWNER �_''
6 OWNER'S NAME c / ) STREET ADDR SS 7 JD / iGGi` i n DA � ,eit l � /1 ,' (/ rL c z (CC; C
City or Town State . Code .
(Ea3 )- L[(2/_-0 � ' 3
Area code - Phone number
l 11. REMARKS:
5. WELL DETAILS: / Ac.-- •
a. TOTAL DEPTH: t1 elf
b. DOES WELL REPLACE EXISTING WELL? YESg' NO 0 •
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
c. WATER LEVEL Below Top of Casing: a FT. isa NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
(Use " +' if Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER
d. TOP OF CASING IS / 72_ . FT. Above Land Surface' A - 1 `'( g -rH C
lo
. 'Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR I DATE
a variance in accordance with 15A NCAC 2C .0118.
r ``
e. YIELD (gpm): 3 METHOD OF TEST I; t C�e;<r� - i1C1LJ
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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. (919) 733 -7015 ext 568. Rev. 7105