406410_Well Construction - GW1_20120705

QNRESIDENTIAL.wii.. CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERI'LOCATION # 31624
1. WELL CONTRACTOR:
Walter Lea Davis
Well Contractor (Individual) Name
3D Environmental investigations
Well Contractor Company Name
2157 Mocksville H is hwav
Street Address
statesvilie ' NC
•
City or Town State
(704 ) 657-7785
28625
Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WVIVOFOCIQ 4
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MIA)
3. WELL USE (Check One Box) Monitoring 'iMunicipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 6 - o266= � iZ
4. WELL LOCATION:
eAcl)a.Jas &Iva
aifi d
4 Arse
i in/Ay/D/L
ar T
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: C#1S-� C. H4jitie. COUNTY Alov Hs/t'/
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Watley 0 Flat ❑Ridge ❑Other
LATITUDE 36 " DMS OR 3X.xxxxx xxx .DD
LONGITUDE 75 °' " DMS OR NX. xx 000; DD
Latitude/longitude source: E PPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
SLJA?J',$ 4Ofrtt7
Facility Name Facility ID# (if applicable)
.�� 13 r i.4cia $ eh/c�
Street A dress
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C' or To
wn
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Conta Name
� 1
at I
or T
ity
M fgdres.
IA
Town
( 5/0 ) ,7”1 —
Area code Phone nurnber.
6. WELL DETAILS:
a. TOTAL DEPTH: I e2
4, n oh n
d. TOP OF CASING IS FT, Above Land Surface*
*Top of casing terming at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
: e. YIELD (gpm): • METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
: Top Bottom
Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
• Thickness/
:7. CASING: Depth Diameter Weight Material
Top 0 Bottom o2 Ft. S'cXi ci° /re -
Top Bottom , Ft,
Top Bottom Ft.
8. GROUT: Depth Material
Top Q Bottom / Ft. eleh'! tK
Top...... Bottom......... _. Ft. -_... ... _
Top Bottom . Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top a Bottom a Ft .2 in. 0410 in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Method
tek"4".
10. SAND/GRAVEL PACK:
• Depth Size Material
Top 1,2 Bottom /4.2 Ft..0p2 S,4r1c' .
Top Bottom Ft.
Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
/
AZ olfe(fc? 5 .
/
. State Zip Code • /
•
diA#V) : /
:
1
/
/
}VC .2W:
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO V
c. WATER LEVEL Below Top \of Casing: FT.
(Use '+A if Above Top of Casing)
•
•
• 12. REMARKS:
Formation Description
IS K n � CrySt4Q;y
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ranori�_•.Ayi 4C �'iUnit
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: I DO HEREBY CERTIFY THAT THIS WELL. CONSTRUCTED IN A CORDA E wrni
• 15A NCAC 2C, WELL ' • NSTRU « ION • • S, AND THAT A COPY OF THIS
RAC D - �= •ROVID-.;/ • 47:Eft� •
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SIGNATURE F CERTIFIED WE
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CONTRACUMC oar
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PRINTED NAME OF PERSON CONSTRUCTING, THE YELL'
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FI GW-lb
Rev. 2/09