HomeMy WebLinkAboutWELL-09-2014-053691.TIFApr 19 07 12:39p Dan Huffman 828.397.6701 p.2
~~''~
WELL CONSTRUCTION RECORD ~~
North Carolina - Department of Environment and Natural Re ounces -Division of Water Quality -Groundwater Sectio~~n~n//~~ ~~
WELL CONTRACTOR {IiYDMDUAL) NAME (print) O S- CERTIFICATION q~L
~ J P1tONE i3 (~'1 ..3~` ~~~
WELL CONTRACTOR COMPANY NAME ~
STATL WELL CONSTRUCTION PERMTTB OCIATED WQ YSRMTTM
(if applicable) (ifapplicahle)
1. WELL USE (Check Applicable Box): Rss~idential~ Mynicipal/Public ^ Industrial O Agricaltural d
Monitoring ^ recovery ^ Hcat Pomp Water Injection ^ Other ^ If Other, List Use
2. WELL LOCATI N: ~
l~'
' ' TopographiclLand setting
^Flat
DValle
OSl
' County
Nearest Town: y
ope
^Ridge
-$ (~app~~>~
(StreetName.N Cm~mtrnity,ytithcyvssioo,latNo~TlpCodt) LatitndeJlongitudeofweIllocation
3. OWNER ~ (SeD~d')
IBtitude/longitude sot>zce:^GPS^Topograpbic map
~~~
xp~ No_)
/
~
/~
/'~
~cf'
S~ (~ 6os)
Dom' DRI[.LiNG I..(~C
y
~~r
~~
-
.
_
chy or Town Sta®e T.tp Code From To Formation Description
~)'
Ares codo- Phanc Dumber
' -07
D`f ~
.
4. DATE DRILLED
5. TOTAL DEPTH: ~`/'~ -
6_ DOES WELL REPLACE E)USfiNG WELL-? YES O NO ~
7. STATIC WATER LEVEL Below Top of Castng: ~~ FT.
(Ux °`~ i! Above Top of Ct~~
8. TOP OF CASING [S Z FT. Above Land Stuface•
'?op or raatos terminded at/or below reed rr+r6ee regnlrer a
vnrianee to •erardance alto 15A NCAC 1C .O11S.
9. YIELD (gpm): 7~ -_ ME'i'HOD OF TEST ~ /
t0. WATER ZONES {depth); T ATIQ~l SKETCH
1 i. DISITiFECTION: Type Amotmt X02 Show direction ~ ~~~ m ~~ ~ ~ leavt
two State Roads m Couaiy Roads. Include the road
12. CASING. WaII Thidmess
~~y~
l c~~4. L~ 957~7L
T~ L~2 Ft numbers and wmmon road names.
.
Fro A~
From To J
From To F't:
13. GRO(3T: Deptlt Manorial ethod
~ ~ ~ ~~i ~L N,~ G ~I ~,~D
,
3A
Frost r> To~_ Fi.~~{ f ~ ~~~~,
~ .~
u
Frorr>r To Ft.
l
M
i ~ 1'
ater
a
14. SCREEN: Depth Diameter Slot Sim (~
FrorrL To Ft___.~n. in.
~
From; To Ft. ia. in.
C ~p
I ~~ ~ d
K:
15. SAND/GRAVEL PA ~r
Depth Size Material ~ J~
\
'r
Front To Ft. Gt/~Lli
s
(o
From To Ft.
16. REMARKS•
I DO HER®Y CERTIFYTHAT THIS 1'VELI. WAS CONSTRUCTED IN ACCORDANCE WITH I SA NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF TH]S RECORD HAS BEEN PROVIDED'i'O THE VvBLL OW[JER
SIGNATURE OF PERSONCON'STRU~ NGTHEWELL UA1C
Submit the original to the Division of Water Quality, Groundwater Sectlon,1636 Mail Service Center -Raleigh, NC
27b49-1636 Phone No. (919) 733-3221, within 30 days. GW-I REV. 07/2001