HomeMy WebLinkAboutWELL-12-10-13592.TIF r•:o
` .> ' .its
. c 1 � ESID .T L4L WELL CONSTRUCTION RECORD
NirN'
,, _ 1 / rt ' ,� s North Carolina Department of Environment and Natural Resources- Division of Water Quality
_� ° / -
SWELL CONTRACTOR CIERTIFICATFCD �l # .5 / `
1. WELL CONTRACTOR: , g. cc T��ER ZONES (de t
/ / /'/ 5/' t1 / Top /C Bottom , � Top Bottom
Well C ntractor (Ind' dual) Name %� J > ^ Top Bottom Top Bottom
G-� 1 z fe / 1 �r / -1'! / //1l{ f • Top Bottom Top Bottom
We ntractor o pany Name
P • 0 °
1.0x / y 6 - l� J f 7. CASI G: Depth D1 /meter Thickness/
t riat
I � / ' • t Address d / Top L ' Bottom / F L' [ {y /
x r Top Bottom Ft
City or Town State Zip Code
(X " F) , [ _ (3 o o g Top Bottom Ft._
Area code Phone number 8. GR T: Depth 4 Material Method
2. WELL INFORMATION: / Top C BottonT7W Ft. C �J •C {" ve ` -
WELL CONSTRUCTION PERMIT# /2 - / ° / 3 6' 72 Top Bottom Ft.
OTHER ASSOCIATED PERMIT #(it applicable) Top Bottom Ft.
SITE WELL ID #(it applicable) 9. SCREEN: Depth Diameter Siot Stze Material
3. WELL USE (Check Applicable Bo Residential Water Supply` Top Bottom Ft in. in.
DATE DRILLED /02 r� AI Top Bottom Ft. in. in.
TIME COMPLETED AM 0 P Top Bottom Ft. in. in.
4. WELL L ATION: 10. SAND/GRAVEL PACK
G _ / � �� . Depth Size Material
CITY: L fv G C (/J Top Bottom Ft.
//',.3 /yeti, L/ (e9 fs-' Top Bottom Ft
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) Top Bottom Ft.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
fl Slope ° Valley `Flat ❑ Ridge ❑ Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE 36 " DMS OR 3X.X00xxxxXX DD
LONGITUDE 75 XxxXXXX
" DMS OR 7X.XX DO / Red " LS-dit
Latitude/longitude source: [J3PS :Topographic map // Al 0�� fi • _ . /
(location of well must be shown on a USGS topo map andattached to - i ' I
this form if not using GPS) /
K
5. WELL O f - - - �ja= s—��l�l�
f eA S ilibr . 1 7 ( ( /
Owner Name / /
Street Address /
/
City or Town State Zip Code /
(K 7 g") g') . ,- 8 -- 60 /
Area code Phone number
6. WELL DETAILS: �� - -
12. REMARKS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES u NO-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 51 C FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use " +" if Above Top of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
d. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require PROVIDE THE LL OWN re
a variance in accordance with 15A NCAC 2C .0118.' SIG UR OF C RTIFI u� LL CO " ' C OR TE •
e. YIELD (gpm): 3 ETHO OF TEST At / /
f. DISINFECTION: Typ Amount ' . PRINTED E OF ERSON 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) 807 -6300 Rev. 11 /08