HomeMy WebLinkAboutWELL-5-11-18042.TIF �l�a��
WELI. CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print)�CI �3/�.d ICL 11 C1S,S�.�/ CERT[FICATION #�qa�
WELL CONTRACTOR C01�7PANY NANIE �/n,�S /��..P. ��,Q.LI / /�/��/ �/11 PHONE # (� �l � 7�
S"CATE �VELL CONSTRUCTION PERAIIT# ASSOCIATED �VQ PER�IIT# 3`�I '�[Yc�� oZ
(if applicable) (if applicable) _ _
1. WELL USE (Check Applicable Box): Residential � MunicipallPublic ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery ❑ Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATION: Topographic/Land setting
Nearest Town: ('L�l����X�� County ('�'fL1 tt/�7�1 �Ridge ❑Slope ❑Valley ❑Flat
�,�l�[ �'� ��j� p fi/ c�T (check appropriate box)
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code) Latitude/longitude of well location
3. OWNER: L31�.[JC' ["��`P--�1U� (degrees/minutes/seconds)
Address //('•, � �/�// P 14i• ST __ Latitude/longitude source:�GPS❑Topographic map
(Street or Route No.) (check box}
�1�������- 2 ��5'�' DEPTH DRILLING LOG
e;ry or Town scace Zip Code From To Formation Description
(_,�')- a2�F�— �2 ,Y�ll i�/--� /�,5 � Pk� c/ S� /sT jFn ��
Area code- Phone number
4. DATE DRILLED S� �� �L1 �— �� S' T`� ���-5 ��q i"f,,Q ,' Q"_�
5. TOTAL DEPTH: �fi��
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO �
7. STATIC WATER LEVEL Below Top of Casing: �,_�__FT.
(Use "+" if Above "Iop of Casing)
8. TOP OF CASING IS � FT. Above Land Surface* —
*Top of casing terminated at/or below land surface requires a '
variancc in accordancc with 15A NCAC 2C .0118. . �
9. YIELD (gpm): _ METHOD OF TEST A/ _
10. WATER ZONES (depth): �n FT�
LOCATION SKETCH
11. DISINFECTION: Type Amount;- C_�c,e�.,d_ Show direction and distance in miles from at ]east
12. CASING: Wall Thickness two State Roads or County Roads. Include the road
��Depth� Diameter or Weight/Ft. Materi� numbers and co � on road names.
From To 7. Ft._� Lb' i �.�� Q
From To Ft. � � ,(� ��
From To Ft. ��� �
13. GROUT: Depth Material Method `� �
From To �_ Ft. .��e�/A/i 1``-! , s �c� D
Prom To Ft. ('���/J� 3 �
14. SCREEN: Depth Diameter Slot Size Material �
From To Ft. in. in. �
'1�
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Materiai
From To Ft. �!`
From To Ft. � � � � � ro �
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE �VITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O�'VNER
0[7' .a.� c �i�► �L,/ 5' /� � / /
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 �Iail Service Center - Raleigh, NC
27699-1636 Phone No. (919) 733-3221, within 30 days. GW-1 REV. 07/2001