4507 Hwy 64W (2) co
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RESIDENTIAL WELL CONSTRUCTION RECORD RECEIVED
North Carolina Department of Environment and Natural Resources-Division of Water Quality DEC 0 2 2015
WELL CONTRACTOR CERTIFICATION# 2901
DC HEALTH
1.WELL CONTRACTOR: g. WATER ZONES(depth):
CHAD HARTNESS Top 289' Bottom 290' Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
AIR DRILLING. INC Top Bottom Top Bottom
Well Contractor Company Name Thickness/
176 COMMERCE BLVD 7. CASING: Depth Diameter Weight Material
Street Address Top 0 Bottom 77 Ft.6" PVC
STATESVILLE NC 28625 Top Bottom Ft.
City or Town State Zip Code
7( 04 872-7614 Top Bottom Ft.
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 Ft.GROUT POURED
WELL CONSTRUCTION PERMIT#197344 Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#('rf applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Sf Tope Bottom Ft. in. in.
DATE DRILLED 11-6-15 : Top Bottom Ft. in. in.
TIME COMPLETED 3:30 AM❑ PM Top Bottom Ft. in. in.
4.WELL LOCATION: : 10.SAND/GRAVEL PACK:
CITY: MOCKSVILLE COUNTY DAVIE Depth Size Material
Top Bottom Ft.
4507 US HWY 64 W Top Bottom Ft.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope []Valley ❑Flat []Ridge ❑Other 11.DRILLING LOG
LATITUDE 35 °52 446.0000 Top Bottom Formation Description
"DMS OR DD 01 67 DIRT
LONGITUDE 80 °42 151.0000 "DMS OR DD 67' /305' ROCK
Latitude/longitude source: [ PS Qfopographic map /
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) ! l
5.WELL OWNER /
MUNDY REALTY /
Owner Name /
2001 NEW WALKERTOWN /
Street Address /
WINSTON-SALEM NC 27101 I
City or Town State Zip Code /
Area code Phone number
6.WELL DETAILS: 12. REMARKS:/�'�
a. TOTAL DEPTH: 3055 FT ('
b. DOES WELL REPLACE EXISTING WELL? \YES❑�a NOL(
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 40 FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+"if Above Top of Casing) STANDAR S,AND TH4T A COPY OF THIS RECORD HAS BEEN
VID TO LL
d. TOP OF CASING IS 1 1/2 FT.Above Land Surface' 11
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.01 18. SIGNATURE OF CERTIFIED WELL CONTPACTOR DATE
e. YIELD(gpm): 6 METHOD OF TEST AI RM � 5 S
f. DISINFECTION:Type HTH Amount PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality- Information Processing, Form GW-1a
1617 Mail Service Center, Raleigh,NC 27699-161, Phone: (919)807-6300 Rev.2109