HomeMy WebLinkAboutWELL-11-10-13334.TIF a sT^rtd,
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i.S - Y „ � `, , RESIDENTIAL WELL CONSTRUCTION RECORD
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,�, � North Carolina Department of Environment and Natural Resources- Division of Water Quality
- , ' 7 WELL CONTRACTOR CERTIFICATION # 2584A
1. WELL CONTRACTOR: g. WATER ZONES (depth):
ALAN S. GANTT Top 276 Bottom 277 Top Bottom
Well Contractor (Individual) Name Top Bottom Top Bottom
CAROLINA WELL DRILLERS. INC. Top Bottom Top Bottom
Well Contractor Company Name
Thickness/
522 GANTT'S GROVE CH. RD. 7. CASING: Depth Diameter Weight Material
Street Address Top +1.5 Bottom 160 Ft. 6 1/8 SDR2I PVC
MOORESBORO NC 28114 Top Bottom Ft.
City or Town State Zip Code
( 704 ) 434 -7277 Top Bottom Ft.
Area code Phone number 8. GROUT: Depth Material Method
2. WELL INFORMATION: Top 0 Bottom 6 Ft. GRAVEL MIX GRAVITY
WELL CONSTRUCTION PERMIT# 11-10-13334 Top 6 Bottom 20 Ft. HOLE PLUG GRAVITY
OTHER ASSOCIATED PERMIT #(it 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 liff Top Bottom Ft. in. in.
DATE DRILLED 2/22/11 Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
TIME COMPLETED 11 AM Iji PM ❑
4. WELL LOCATION: 10. SAND /GRAVEL PACK:
Depth Size Material
CITY: MAIDEN COUNTY CATAWBA Top Bottom Ft.
4849 NC16 HWY Top Bottom Ft.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) Top Bottom Ft.
TOPOGRAPHIC / LAND SETTING: (chec( appropriate box)
❑Slope ❑Valley 'Flat ❑Ridge ❑Other
11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 35 • 35 ' 4.0000 " DMS OR 3X.)XXXX7000( DD 0 / 151 CLAY
LONGITUDE 81 " 5 ' 52.0000 " DMS OR 7X.XXXXXXXXX DD 151 / 300 CONSOLIDATED ROCK
Latitude /longitude source: Q 3 PS ❑Topographic map /
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) /
5. WELL OWNER /
BANDY'S CROSS RD VFD /
/
Owner Name
/
4849 NC16 HWY /
Street Address /
MAIDEN NC /
City or Town State Zip Code /
(704 ) 746 -4985 /
Area code Phone number 12. REMARKS:
6. WELL DETAILS:
a. TOTAL DEPTH: 300
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Iii
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 82 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 1.5 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118. SIGNATURE OF CE 0..,14> � ED WELL CONTRACTOR DATE
e. YIELD (gpm): 6 METHOD OF TEST ARDM ALAN S. GANTT
f. DISINFECTION: Type HYPOCHL Amount 12 OZ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW -la
1617 Mail Service Center, Raleigh, NC 27699 -161, Phone : (919) 807 -6300 Rev. 2109