HomeMy WebLinkAbout413142_Well Construction - GW1_20130429rJ4/ L1 / L Ji 3 J 7 . J4
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1. WELL CONTRACTOR:
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Well conaEcior (Individual) Name
NONRESJDEPITJAL WELL CONSTRUCTION RECORD
...r.r..,,ne
•
' WeM COntraclor Company erne
Street address
City or Town
( 1.5-17 VI
Area code Phone number
t WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMRV(Noppinge)
SITE WELL, ID Op sweat*
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
d. TOP OF CASING 18 , tI FT. Above Land Surface'
'Top of casing terminated et/or below land surface may require
•
a variance in accordance with 1SA NCAC 2C .0118.
: e. YIELD (gpm): � METHOD Of TEST u►.
E DISINFECTION: Type Amount
g. WATER ZONES (depth):
1/41 vt)C QC‘:Top- Bottom _..
State Zip Code : Top
Top
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Imgationk Other 0 (het use)
DATE DRILLED ' A-" a_
t. WELL LocAroN.
(Street Horne, Numbere
CITY:..2,J44
Lot No., Parcel, Zp Code)
COUNTY
TOPOGRAPHIC / LAND SETTING: peak appropriate box)
O Slope Oval* Grit 0 Ridge 0 Other
LATITUDE 3d3 q.,. DMS OR 3x,30000tXxxX DD
LONGITUDE *71°_,T21,1_,T1.2 DMS OR h,u, D0
Ladtudellongitude source: [IS C]ropoo map
(location of wet/ must be shown on a USGS topo map andettachad to
this loan if not using GPS)
6. FACILTI Y (Name of the business where the well is located.)
44,er
F Name
Street Address
Facility IDS Of appkable)
City or Town ate Zip Code
Contact Name
Mailing Address
City or Town
LIOIMAffillbJ
Area code Phone number
I. WELL DETAILS:
s. TOTAL, DEPTH:_ 3
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO oo
c, WATER LEVEL Below Top of Casing: / 19"" .
(Else '+' if Above Top of Casing)
FT.
Top t3otio
Bottom Top Bottom
Bottom_. Top Bottom
4 13142
7. CASING: Depth Diameter
Top t, (� . Bottom D.0 Ft•- .,.
TopBottomFt,
Top Bottom Ft
: 8, GROUT: Depth Material
Top 0 Bottom I u Ft. 110(Al1(
TopBottomF
Topes Bottom Ft.
0, SCREEN; Depth Diameter Slot Stu
• Top_ Bottom, i :Ft.j Y, In. OL P in,
Top Bottom F in. In.
Top Bottom Ft.In. In.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom _ Ft.
Top Bottom Ft
Top Boom�� Ft,
Thkknassl
Weight
Sak'IU
Method
Pe u�I'
: 11, DRILLING LOG
Top Bottom
L/ 5 '
/ 41.110111.1111•.. •
• 1
/
/
1L REMARKS:
Formation Deaaiptlon
•s)0.4/41.
G cU P _
4f `tti Y E
C I 4
.:s •E` ORMi 6. � �,x 6�Sg Utii
- 1 pp HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 14 ACCORDANCE wmi
15A PCAC 2C, WELL, cote Ruc'noN STAND Rt76. AND THAT A c Pf or mie
RECOA ' • BEEN PROVIDED v THE OWNER.
'? /
SI TUR OF CE 1- • WELL, CONTRAC1R DATE
PRINTED OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mali Service Center. Raleigh. MC 27695441. Phv►no - i91 a1 Rf7.1MA
RECEIVED 04-21-'13 20:17 FROM- 9103133102 TO- NC DENR P&S
Form GW l b
Rev. 2I09
P012/012