403633_Well Construction - GW1_20120313

1. WELL CONTRA, T R:
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NONRESJDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources:- Di ision of Water Quality
WELL CONTRACTOR CERTIFICATION #
Q
: d. TOP OF CASING IS '-i,
Well Contractor (Individual) Name
iAt((-1;
SR . <--)
. W II Fart ' for Com mpany Name
_:4j, i) ci b H GU 1
S reet Addre _
H CIA (\11 i)3'-feCtC•
�C,,ity or Town
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Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
(4(
194. 0 3 77, 3. 3
FT. Above Land Surface*
• *Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .g118.
• ta. •'• fi
e. YIELD (gpm):
▪ f. DISINFECTION: Type
ETHOD OF TEST
Amount
C{ g. WATEZOES(deptf�'jgLf9 Top =- Bottom "- , Top Bottom
State Zi Code CP : Top `) Bottonf Top Bottom
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation.5ther (list u,§e)
DATE DRILLED —
r),fr*S.--
8. GROUT: Depth i Material % Meth : r
Top () Bottom Ft. -- .-..., t fo u
` c"
Tod'" � 0Bottom- Ft. 1-- (,-fy,ft T (e''' i
Top Bottom Ft.
4. WELL LOCATION: r 9. SCREEN: Depth ;� Diameter Slot Size Material
-•••)•,..) 14• • . Top r•PN, Bottom Ft. in. h in.
(Street me, umbers, Community, Subdivision, Lot No:, Parcel, Zi '
Y P.Code
Top • Bottom Ft. in. in.
CITY: A(3iCfl ! COUNTYWU I hi Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley I .Flat O Ridge DOther : 10. SAND/GRAVEL PACK:
Depth Size Material
LATITUDE 36 " DMS OR 3X.XXXXXXXXX DD : Top Bottom Ft.
LONGITUDE 75 " DMS OR 7x.xxxxxxxxx DD : Top Bottom Ft.
Latitude/longitude source: ❑GPS ❑Topographic map : Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) : 11. DRILLING LOG
5. FACILITY (Name of the business where the well is located.) : Top Bottom
a
.)- 7c.
Facility Name Facility ID# (if applicable) : 3---�.. / )
,.. \ /.,... C(3uo
Street Address ; / i
i
City or Town State Zip Code / 170
Formation Description
Contact Name •
•
• /
.
Mailing Address • /
City or Town State, Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
i 3#
N O °'`�
c. WATER LEVEL Below Top of Casing: FT.
l'Ic\
b. DOES WELL REPLACE. EXISTING WELL? YES ❑
(Use "+" if Above Top of Casing)
Top
Bottom Top Bottom
'Thickness/
7. CASING: Depth Diameter Wei ht Material
4- Bottom: fr
Top Bottom Ft.
/
12. REMARKS:
, rye 'cane,/
e t
MAR i + 2012
QWf?/B£G
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WE i CONSTRUCT 'N STANDARDD,M D THAT A COPY OF THIS",
RECORD1 BEE PRf IDE O THWEL WNER. .
: / /1/
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SIGN TURE'Or C R 1,WELL�ONTf�ACTOF�.. DATE
VACC
PRINTED NAME OF PERSON CONSTR
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
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Unit