HomeMy WebLinkAboutWELL-3-11-16151.TIF `' RECEIVED
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�� , � ,,: . a� .�SIDENTIA� W�LL CONSTRllCTION RECORD
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C:� ''1 "� , °g North Carolina Department of Environment and Naturat Resources- Division of Water Quality CATAtN9A C{3iN�ii1P
�.'� � «y,,, �•=� ,� � . ERMROIV�N¢iJT� M�EJ�t?F!
� WELL COI�TRACTOR CERTIFICATION # � � ��J �
�. WELt CONTRACTOR: f. OISINFECTION: Type t�tT 1 AmouM �� '�'��k.i1 "r1�
I� � C�,� v� ., S�� �;: g. WATER ZONES (depth):
Well Contractor (Individuai} Name From�,� To �� From To
�1 C�` v^,'�l CC'.C�� �� ° � �•�- �( � �`� `{l r� ,-L-� From 7o From To
Weil Contrector Gompany Name �-'�— From To From To
STREETApDRESS `�`��l` � ����,`�"�� n c'C�� 6. CASING Thickness/
�„ Depth Qiameter Weight Material
� C t'C�C\ �.:t'x i�� *�_ ��c :(� C- � From �„� r. l.� Ft.
City or Town State Zip Code From 7o F�
+�`( `�` ) ;�y,�y `'����, From To Ft.
Area cod� Phone number
7. GROUT: Depth Material Method
2. WELL INFORMATION: ��y '"1 •'� -'
From C1 To ,,,�4.� Ft. be�`�07'���rC� �c.u<<t
SITE W ELL ID #(it appii�able) From To Ft.
STATE WELL PERMIT#(itapplieable) WeI (` 3 �'' `- ( WI S I From To Ft.
r DWQ or OTHER PERMt't#(if applicable) 8. SCREEN: Depth Diameter Siot Size Material
From To Ft. in. in.
WELL USE (Check Applicable Box): Residential Wster Supply � From To Ft. in. in.
DATE DRtLLED 3�'�rl 1 From To Ft, in. in.
TIME COMPLETED I oZ = O G� AM Q PM p g. SANDIGRAVEL PACK:
3. WELL LOCATION: � Depth Size Material
� 1 � G� i COUNTY ����` From To Ft.
CITY: From Ta Ft.
� � �j �G �,.m�t i� l _Q-� �. {�� pZ-C'�-'I From To Ft.
(Street Name, Numbers, Communi , Subdivision, Lot N., Parcel, Zip Code) ' �
TOPOGftAPHVC / LAND SETTING: 10. DRILLING LOG
❑5lope pValiey ❑Flat ❑Ridge Oother From To Formation Description
(check appropuate box) � -� �O �p�G,� 5/
�+ -� �'�� May be in degees, T
LATiTUDE �, J ___y��� minutes, seconds or ��------� Z— � � °''" ' '"
LONGITUDE �� �j in a decimal fortnat ,� �U` -�/ � D l vr�ti, 1
� z!� � L 8'S � � � �cti .
Latitude/longitude source: qGPS ❑Topographic map ���f �� � . S
(focatron of weft must be shown on a USGS topo map and
atteched to this form c7not using GPS)
d. WEtL OWNER � .,,�,� `(�/� +
OWNER'S NAME �TL il'�� I►' 1 I 1 e.r
TREETAD�RESS I I �� �I�ifl �bce
� ~ Gat �
City or Town � Zip Code
���� ��{' �r 3 c�`,�2
Area code - Phone number
11. REMARKS: ��
5. WEII DETAILS: / � � [�JQ..��� (��P$�✓ � v
a. TOTAL DEPTH: [ q V� ��4 b�_
b. DOES WELL REPLACE EXI3TING WELL? YES ❑ NO p�
I DO HEREBY CER7IFY THAT THIS WELL WAS CONSTRUCTED Pl ACCORDRNCE WRli
C. WATER LEVEL BBIOW TOp Of C3SIf19: FT. 15A NCAC 2C. WELL CONSTRUCTION STANDAROS. ANO 7HAT A COPY OF THIS
(U6@ °+" if Above Top of Casing) RECORD HAS BEEN PROVl�EO TO THE WELL OWNER.
d. TOP OF CASING {S � � � FT. Above Land Surface° `j'�L" t'� ' ., ��- �'-�-'�-� .-� ( �
•Top of casing terminated at/or betow land surface may require SIGNA7URE OF CERTlFIED WEIL CONTRACTOR DATE
a variance in accord nce with 15A NCAC 2C .01 �8, ��
e. YIEl.D (gpm): � METHOD OF TEST �� � � `�� � � �'��t� t `��-� ' ���'�CL L�J
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the originai to the Division of Water Quatity within 30 days. Attn: lnformatfon Mgt., Form �w-�a
1617 Mail Service Center - Raleigh, NC 27699-1617 Pfione No. (919) 733-7015 ext 56�. Rev. 71n5