413144_Well Construction - GW1_20130429

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ALUM M W .LL
•
Street Andres`
City orTown
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Area ands Phone number
Z. WELL INFORMATION:
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1(44 , 1 f; ,,1
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1. WELL CONTRACTOR:
'73
Weil contrfcta (Individual) Name
—4(2.-kts," LA Old I ts'S
Well Contractor company Name
_DLO AAP_Q. .t7 . Z4-
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State Zip Code
WELL CONSTRUCTION PERMIT
OTHER ASSOCIATED PERMIT** appbie)_,
SITE WED, ID * eppllcable) .�,.
3. WELL USE (Check One Box) Monitoring 0 Munlctpal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 iniectlon 0
Inigatiorg Omer 0 nisi use)
DATE DRILLED 3 ' !a 7 ' i
4. WELL LOCATION:
3 F o (A) f ANJ L.
(street Nemo, Nufnbevv, Community, Subdivision, Lot No.. Parcel. Zip Code)
CRY: & tCOUNTY 441.4
TOPOGRAPHIC l LAND SETTING: (csedt appropriate box)
oslope 0Va t Q 0other
LATITUOE �j °' 3 S N oM3 OR 3x.xxxxxx o x op
LONGITUDE �•,� 9 (M DMS OR ?x.X00
Latitudellongltude eourve; GAPS Oropogr hic map
(Iocedon of well must be shown on a USGS topo mop andattached to
this town if not using GPS)
6. FACILITY (Name of the business where the well is rotated.)
FY�r �rt►s
&e91 Address
City or Town
Facility ID* Or applicable)
State
Zip Code
Contact Name
Meiling Address
City or Town
State Zap Code
Area code Phone number
O. WELL DETAILS:
•. TOTAL DEPTH: .3 r
b. DOES WELL REPLACE EXISTING WELL? YES a NO X
c. WATER LEVEL Below Top of Casing: 4 FT.
'+' if Above Top of Casing)
NONRESJDENTIAL WELL CONSTRUCTION ,RECORD
North Caroline Depattfient of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ?-/
d. TOP OF CASING t6 1 FT. Above Land Surface'
"Top of casing *minuted at/or below land surface may require
: a variance in accordance with 15A NCAC 2C ,011 e.
e. YIELD (Opm): o METHOD OF TEST __ me
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top. Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7, CAGING: Depth Diameter Weight Malarial
Top _Bottom �.vFt. g)"f f, SC tie dL
: TopBottom Ft.
: Top Bottom, . FL
41 31 4
8. GROUT: Depth Material Method
Top Bottom o Ft. "aur
Top BottoommFL
. Top Bottom Ft
0. SCREEN: Depth Dlamatitt Slot 9u Motorist
Top , i , F1.1 YY in. 0/4 in. ,,7
Top Bottom FL In. tn,
('Top saao
in,
: 10. SAND/GRAVEL PACK:
Depth Slate Material
Top Bottom Ft.
Top BottomFt.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
/ o
I f`r
/
/
12.R KS:
Formation Descrlpton
fn4 Y^ tr..j �� Li
Mk__
10L! HaREer CERTIFY THAT THIS V.VLL WAS cotarauG?Eo w AcooRtw1ce vemi
• iaA N .14 2C, WELL STANDARDS, ANO THAT A COpf Of TFIS
RE= • - -.:�. roTHE WELL OWNER.
SI
PRINTED NAME
Pe) I 3
FED WELL GONTRAC'raR DATE
CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mali Service Center, RaieIDh, NC 27699•161. Phone : t919t 80743U0
RECEIVED 04 - 21-' 13 20:17 FROM- 9103133102 TO- NC DENR P&S
Farm GW tb
Rev. MN
P010/012