411607_Well Construction - GW1_20130211

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4183-A
1. WELL CONTRACTOR:
Michael Paul Brown
Well Contractor (Individual) Name
Mad Dawa, Inc.
Well Contractor Company Name
1006 Camp Creek Rd.
Street Address
Iron Station NC 28080
City or Town State Zip Code
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERM1T# INA
OTHER ASSOCIATED PERMIT#(if applicable) (iti,
SITE WELL ID #(if applicable) �'Pa Q•
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED Oil 11 1 20 i 3
4. WELL LOCATION:
5.i1() tAckr144'
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
1
CITY:LI:V(1/C% kD Y1 COUNTY 1tw IANAIDVCr
TOPOGRAPHIC./ LAND SETTING: (check appropriate box)
❑ Slope [Valley ,Flat ❑ Ridge ❑ Other
LATITUDE S.8 3q ° i t(($0 "DMS OR 3X.XXXXXXXxX DD
LONGITUDE 51077 ° ' ((at "DMS OR 7x.xxxxxxxXx DD
Latitude/longitude source:1GPS [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.)
$r4v , (4'orrvtcr")
Facilityme FacilityID# applicable)
( if pP )
CI3Q fer&+ ,+
Street Address
tftt;Ackkot S4O(0
City or Tov kb State Zip Code
P ;Pt( 1-10.,v_kithAtki,I0C6,A) enk-V646Corp
Contact Name
0►O D'`7
Mailing Address
. 4; INSFO'
City or Town V
( i ) L470
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO)J
c. WATER LEVEL Below Top of Casing: tdp FT.
(Use "+" if Above Top of Casing)
411607
d. TOP OF CASING IS ' FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
• a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): jU A METHOD OF TEST A4
f. DISINFECTION: Type VA Amount 1th4
g. WATER ZONES (depth):
Top 040 Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top 0 Bottom
: Top Bottom
Top Bottom
8. GROUT: Depth
Top 0 Bottom 3
Top ' Bottom
Thickness/
Diameter Weight Material
Ft. a soh 40 VC
Ft.
Ft.
Material
Ft. PO�1G�.�
Method
90v�`
Ft. (ein.4oyi.:-Ce.. Pour
Top Bottom Ft.
9. SCREEN: Depth
: Top Bottom t 5
Top Bottom
Top Bottom
Diameter Slot Size Material
Ft. d in. 'MO JO in. Pitt
Ft. in. in.
Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size
Top L1 Bottom lc Ft. aofgo
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
a /
•
• / I0
• 0 / }
•
•
•
•
/
12. REMARKS:
Material
Formation Description
4`0 tAiv ‘4.K.1
&ova& S i � a►.«. �1
6re ,.Thf Sa �
•
L,„J
cEP $r.,9
./1113
41ff i "ar ro �26 r TOCE'S Ayi(/ I•�l
yam
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCT ,D N ACCORDANCE, WITH
. 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND'THAT A COPY OF THIS
: REC R HAS BEEN PROVIDED TO THE WELL OWNER N, `4,k ,,,/'!
• %p r Y II . '
* -.2C: „.4.-...".....------
: SI NATURE OF CERTIFIED WELL CONTRACTOR DATE
: Michael Paul Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09