405257_Well Construction - GW1_20120521

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # Lit &�C
1. WELL CONTRACTOR:
L.34.44
Well Contractor (Individual) Name
Well Contractor Co Y
an Name
io I', tdr
Street Address _
745
City or Town State Zip Code
( 7 6'4 ) 11 z- O` ,
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# ii/r/f
OTHER ASSOCIATED PERMIT#(if applicable) AK/
SITE WELL ID #(if applicable) •'tAl 7
3. WELL USE (Check One Box) Monitoring L1 Municipal/Public ❑
Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED i °
4. WELL LOCATION:
5 60 iVe 1-1- Le, /4, A.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Cri COUNTY / L-.4w
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley &lat ❑ Ridge DOther
LATITUDE { ° ' e 7 t "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 7S 77* 53 ' 413 33" DMS OR 7X.XXXXXXxxx DD
Latitude/longitude source: 403PS ['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.)
Facility Name Facility ID# (if applicable)
V Cad :. - . =- 17 7'41
Street Address
City or Town
ft "4 1141,/e c
Contact Name
80 / 5-5—
Mailing Address
(1)1144v) 2'•; (Ic5s1
City or Town "
( o)?6,
Area code Phone number
6. WELL DETAILS:
C
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
State Zip Code
State Zip Code
NO ❑
FT.
0
d. TOP OF CASING IS FT. Abo• ve Lars "d u ace*
*Top of casing terminated at/or below land surface may require
: a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): lam! METHOD OF TEST
f. DISINFECTION: Type P(/ Amount
: g. WATER ZONES (depth):
Top Ayt Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top a Bottom .Z Ft. 2 F �J-'c Wye,
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth r Material Method
Top () Bottom " Ft. Pc.i-rg•-,-- �`��
: Top f i.. Bottom 2- Ft. Y /?— —
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size .My Material
-
: Top Bottom Ft. in. - C in. ''ram s" .e
Top Bottom Ft. _ in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom / Z Ft.
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
•
0 / C
/
/
12. REMARKS:
Y 21 2012
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCT! c N STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVID;; • ' THE \ ELL OWNER.
SIGNA RE OF CERTIFIED V17ELL CONTRACTOR
•
PRINTED NAME OF PERSON CONSTRUH th/ E D
DATE
-1„12
Submit within 30 days of completion to: Division of Water Quality - Information Processing, 'err `two-1 b
�. I ew.f2 09.
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing Uni