413146_Well Construction - GW1_20130429

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1. WELL CONTRACTOR:
Well ctor (Individual) Name
_4.4=44 P4-
Well Contractor Company Name
r) a • _
Street Addresa
C ty or Town
NONRISJnENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of tinvironrnenc and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # g `�
d. TOP OF CASING IS /f FT. Above Land Surface'
• 'Top of casing terminated atlor below land surface may require
a variance In accordance with 1 SA NCAC 2C .0118.
a. YIELD : �� METHOD OF u► Om): TEST
I. DISINFECTION: Type _ Amount
9. WATER ZONES (depth):
Top Bottom Top Bottom
. r4). ryos
State Zip Code
c_le2.) • 3f/f?
Area Dods Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT/1
OTHER ASSOCIATED PERMIT/(Aapplleebie)
SITE WELL I0 all •P e)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Corrimercial 0 AOricuttural 0 Recovery 0 In)ect on 0
InigationO Otter 0 (list use)
DATE DRILLED _ .'g7
4. WELL LOCATION:
6 a c17-
(Street ► em*, M o nOero, Community. Subdivision. Lot No.. Parcel, Zip Colo)
CITY: r .�+ COUNTY ltrea.� /,4,s •�4c'-�"
TOPOGRAPHIC / LAND SETTING: Wed epprooderle tax)
°Slope O Valley o Ffat 0 Ridge O Oilier ,r
LATITUDE 3 Y • pi ' i " DMS OR 3X. XXICXXX,00c DO
LONGITUDE 7 5it'ikhi " OMS OR 7. gCSxxxx DO
Latitude/longitude source: OPS Qropographic mar/
(location of well must be shown on a USGS topo map andattached to
this loan if not using GPS)
6. FACIU1Y (Neme of the business where the well is located.)
FeCiliy Narne
Street Address
City or Town
Contact Name
Maw Address
Facility ID. Of applicable)
State ZIP Code
City or Town
State rip Code
Area code Phone number
6. WELL DETAILS:
e . TOTAL, DEPTH: SAS
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO tK
c.. WATER LEVEL Bekr Top of Casing! )1 FT.
(Use -+' if Above Top of Casing)
Top Bottom
TopBottom
41314E;
Top Bottom
Top Bottom
Thickness/
1. CASINO: Depth Diameter Weight Material
Top rI' i Bottom _ Ft. __ Yek��
Top, Bonom FL
; Top-- 8ot1om Ft
8. GROUT: Depth
Top Bosom
Bottom-
: Top Bottom
9. SCREEN: Depth
Top ro Bottom. 5°
Top - Bottom
Materiel
FL„Ma4L /443
Fl,
Method
eti,r
0� Slot 3 rlel
Ft., / i In....-Qt o In. ¢ .
in,
Fl. In. In.
: 10. SAND/GRAVEL PACK:
Depth Stu Material
Top Bottom Ft.
Top Bottom_ _ _ Ft
Top Bottom Ft.
: 11, DRILLING LOG
Top Bottom
I
/
12. REMARKS:
Formation Description
cde4
CuAr p qA,�
too HeaE6Y CERTIFY TH*t Tae WEu. WAS 4oNerRL cTEQ w ACCORDANCE writ
16A► NCAC 2C, vial. C0NSTRUC f0N STANy1RDS, AN0 THAT A COPY OF THIS
RECORD k - . a . •• 1. WELM OWNER,
SIGNA EOFC
WELL C QR
P7- /I
GAr 70)--5%
(MEQ wine OF PERSON cciHsTRuc*c n,E WELL
DATE
Submit within 30 days of completion to: Uivlsion of Water Quality - lnforrnatlon Processing
17 Mall Service Center, Raleigh, NC 27699-181, Phone : [phone]
RECEIVED 04-21- ` 13 20:17 FROM- 9103133102 TO- NC DENR P&S
Form GW-lb
Rev. 2/09
P008/012