293 Willow Creek Ln (3) •e.:u� RECEIVE-[)
s \' R�SIEN�'L9L WELL CONSTRUCTION RECORD �' i %; f3
e North Carolina D artmcnt of Environment and Natural Resources•Division of Water u
`� Q EIC HEALTH
^�._......•• WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 9. WATER ZONES(depth):
Qavid Grant : Top 6for Battom- Top m_Botto
Well Contractor(Individual)Name Top__Lq a Bottom__ Top-Bottom_
HaiilNAli Qrlll(n17. Iris. : Top ZG1'Bottom Top Bottom ,__,_
Wall Contractor Company Name Thickness/
P.0- RoX 1361 7. CASING: IDapth Diameter Weight Material
Street Address Top 0 Bottom SFS Ft.��' , .S�`I..O2L
ORkRidap, MG-.27 5} _ Top Bcmom Ft.
City or Town State Zip Code _
Top SottorrL , Ft..._„___,__
Area coda Phone number S. GROUT: Depth Material Method
2.WELL INFORMAT ON:
WELL CONSTRUCTION PERMIT* Top. 2_Bottom 3� Ft. 2^ • 64r S )09 k
OTHER ASSOCIATED PERMIT#(Wsppl+cable) Top Bottom Ft.�_
SITE WELL ID#ff awlic.able)_ 9. SCREEN: Depth Diameter Slat Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply j-1 : Top.______Bottom Ft. in. - in.
DATEDRILLED -.8-/3 Tap BaGom`Ft. in. in. -
Top Bottom FL in. _� In.
TIME COMPLETED AM(-! PM[C(
WELL LOCATION _ .
10.SANDMRAVEL PACK. "'
4
!� 11 .. . .,. . fi tie
CITY ,i /�o�CS Viy1lQ COUNTY D0'y+2 :>•S Matartaf
p
To Bottom Ft
rel o w,.,"'C`t`Q 2(� ."L. „ .., Tosottorn` -Ft.
(Street Name Number Community Subdk4on,Lot No Parcel Zip Crede) ,a
TOPOGRAPHIC/LAND SETTING (check appropriate boz)
1
-Slo'pe' :1'1 galley flat �Li ridge "10ther 1.DRILLING LOG
..
„ Top Bottom Fannation'Deai�Iptio.�_...__.
LATITUDE . 77 "DMS Oi3 3X.XXXXXXlCXX f1D C? ,. I .;;12 C
LONGITUDE 10$Q' .-Sly DMS OR 7X.XXXXXXXXX DD21711�YIFI
Latitude/iongitude source: j iPS F Iropographic map S b' l �L� p nd F1.0
n C
(location of well must be shown on a USGS topo map andattached to ��� ��^
�4p� Z
this foam if not using GPS) I
S.WELL
�OWNER r
OnmerName
D.73 l ,/i do w Cr e e.4'<' L o-ri P-
Street Address
City or Town State Zip Code
L 336 ) 4.72- 61.36 I
Area code Phone number :
12. FtEMARKe:
6.WELL DETAILS
a::TOTAL
DEPTH.,—,
biia,:9 •..^ 1 ... .f'DOES
f SGS� NO L-1 __� ._ .... .. ,. ...................:...
� WELL REPLACE EXIBTINQ WELL -
- 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
o°WATER LEVEL'Below Top of Cas)ng FT. ACCORDANCE WITH I5A'NCAC"2C,WELL CONSTRUCTION."'..
if Above Top o/Geeing) : STANDARDS,.AND THAT A COPY..OF.THIS_RECORD HAS BEEN ..
PROVIDE:D TO THE WELL OWNER
d TOP OF CAGING 1S', FT.Above Lund Suiiaae•
«Top of casing temrinated attar below land surface may require /3
a variance to accordance with 15A NGAC 2C.01 S S. SIGNATURE OF CERTIFIED WELL.CONTRACTOR DATE
_ .
s. YIELD(9pm): 3 METHOD QF TEST 2�1 f� .__
t. DISINFECTION.TypaZz -Zo" amount S o Z• PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to:Division of Water Quality- hrlotrnation Processing, Form GW-1a
1617 Mali Service Center, Raleigh,POG 27699.161,Phone:(919)807.8.1Ot1 Rer. l0�