158 McCashin Ln (3) p+ r
' s RESIDENTIAL WELL CONSTRUCTION RECORD
i North Carolina Department of Environment and Natural Resources-Division of Water Quality
RECEIVED
WELL CONTRACTOR CERTIFICATION# 3214
NOV o 3 2015
1.WELL CONTRACTOR: g. WATER ZONES(depth):
RANDY OWNBEY Top 489' Bottom 490' Top DQ
dttbF
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 85 Ft.6" GALV
STATESVILLE NC 28625 Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
704 ) 872-7614
Area code Phone number 8. GROUT: Depth Material Method
2.WELL INFORMATION: Top 0 Bottom 20 Ft.GROUT POURED
WELL CONSTRUCTION PERMIT#193997 Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(d applicable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply Rr Top Bottom Ft. in. in.
DATE DRILLED 10-21-15 Top Bottom Ft. in. in.
:
TIME COMPLETED 3:00 AM❑ PM Top Bottom Ft. in. in.
4.WELL LOCATION: 10.SAND/GRAVEL PACK:
CITY: MOCKSVILLE couNTY DAVIE Depth Size Material
Top Bottom Ft.
158 MCCASHIN 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
Top Bottom Formation Description
LATITUDE 35 ^59 875.0000 ^DMS OR DD 0' /75' DIRT
LONGITUDE 80 "34 ' 712.0000 "DMS OR DD 75' /505' ROCK
Latitudellongitude source: ❑GPS Dropographic map /
(location of well must be shown on a USGS topo map andattached to /
this form if not using GPS) l
5.WELL OWNER /
MARY MCCASHIN /
Owner Name /
158 MCCASHIN LN /
Street Address /
MOCKSVILLE NC 27028 /
City or Town State Zip Code /
U /
Area code Phone number
12. REMARKS:
6.WELL DETAILS:
a. TOTAL DEPTH: 505 FT
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO pf
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) STANDA DS,AND THAT A COPY OF THIS RECORD HAS BEEN
P�TO
P0 ER.
d. TOP OF CASING IS 1 1/2 FT.Above Land Surface"
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118. 1AT E OF CERTIFI WELL CONTRACTOR DATE
e. YIELD(gpm): 2 METHOD OF TEST AI R NI
78 L
f. DISINFECTION:Type HTH Amount PRINTED NA 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.2/09