406629_Well Construction - GW1_20120723

1. WELL CONTRACTOR:
NONRESJDENTJAL WELL CONSTRUCTION RECORD
North Carolina Dcpartmcnt of linviconment and Natural Resources- Division of War Quality
WELL CONTRACTOR CERTIFICATION # 9
: d. TOP OF CASING 18 7 FT♦ Above Land Surface"
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C ,0118.
e. YIELD (gpm►: 4/10 METHOD OF TEST ti
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom_
Top , Bottom Top Bottom
Thick VMS)
7_ CASING: Depth Diameter Weight
Top, iI Bottom d2 if-5 Ft.,
Well Cont c�or (In0lviGuaq Name
0 tti. LA ic
Well Connector Company Name
_ eeAtAAse.2__
Street Address
Clry O � awn
RA
..-.2erk&o?
( 5)/e ► 95y5'P)
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
State Zlp Code
OTHER ASSOCIATED PERMIT:Of applicable)
SITE WELL ID *(if applicable)
3. WELL UBE (Check One Box) Monitoring L Municipal/Public 0
Industrial/Commercial 0 Agricultural a Recovery 0 Injection 0
Irrigatiory Other 0 (list use)
DATE DRILLED 6 "01-- .1
4. WELL LOCATION:
S• '101/ 44 XI('
(street Name, Numbers, Comrrwnity, Subdivision, Lot No., Parcel, Zip Code)
CITY:
6.), /4..
Top-.,... Bottom31.-s, Ft.
Top BottomFt,•in.
TY H A Top
COUN N
TOPOGRAPHIC / LAND SETTING; (check apprnprlate box)
Slope 0 Valley OF I at D Ridge D Other
LATITUDE )&? °, / " DMS OR 3x.XXxXXXXXx DO
LONGITUDE ° ' 2y + DMS OR 7(. cx DD
Latitude/longitude source: ' PS Qropographic map
(location of well must be a wn on a LJSGS topo map anaattached ro
this form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
Chy or Town State Zip Cone
Area code Phone number
6. WELL DETAILS;
a. TOTAL DEPTH: _1`N,
b_ DOES WELL REPLACE EXISTING WELL? YES 0 Nog
c. WATER LEVEL Below Top of Casing:
(Use `+A if Above Top of Casing)
4/57T.
Top Bottom
: 11. DRILLING LOG
r Top Batton
/ c)
/
/✓
1,
/
l
/
= 12_ REMARKS:
•
Bottom Ft. in.
TopBottom+ Ft.
Top_ Bottom_ Ft.
8. GROUT: Depth Material
Top .., ..�♦ .. BottornLL Ft./510/tolioc)
: Top___ Bottom_ Ft.
Top BottomFt.
9. SCREEN: Depth Diameter Slot Size
in. CYO
Material
poe-
Method
/a() Lif
Material
in. (PO
in,
in,
10. SANOIGRAVEL PACK:
Depth Size Materiel
Top Bottom Ft.
Top Bottom Ft.
Ft.
Formation Description
g)44
reihr
00 MEaSBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
- 15A NCAC 2C, wet,t, CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECORD H 5 BEEN PROVIDEO TQ THE ELL OWNER.
SIGNA
URE O CER
PRINTEO NAME OF
Submit within 30 days of completion to: Division of Water Quality -
161T Mali Service Center, Raleigh, NC 27609.181, Phone : [phone]
(,0 %;01' 2
WELL CONTRA OR DATE
QS
RSON CONS UCTI T l
V }—
,.GW-ib
InforrnatlonProcesslnp, JUL 1 6 ii* ila9
RECEIVED 07-14-'12 08:11 FROM- 9103133102
TO- NC DEAfTglgtion Processing P��tA8/012
DWQ/BOG