411606_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
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1. WELL CONTRACTOR:
Michael Paul Brown
Well Contractor (Individual) Name
Mad Dam, Inc.
Well Contractor Company Name
1 006 Camp Creek Rd.
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# t A
OTHER ASSOCIATED PERMIT#(if applicable) )
Ir/ +
SITE WELL ID #(if applicable) l 3 l
3. WELL USE (Check One Box) Monitoring gi Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED V I/! 7/ AO 13
4. WELL LOCATION:
5-136 AA124,,o
NC 28080
State Zip Code
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: \A) s tn,I' COUNTY Mf Hcvcr
TOPOGRAPHIC`/ LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley *Flat ❑ Ridge ❑ Other
LATITUDE as 34. ° 144 ' (� �� " DMS OR 3X.xXxxxxxxx DD
LONGITUDE Ill 77 ° S G � " DMS OR 7X.XXXXXXXxx DD
Latitude/longitude source: E 3PS [(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.)
ri r- CJ V.''O 0fio.0 4 ANC(
Facili LIame FacilityID#(if applicable)
ty pP )
4'130 platKei 5*
State
1%kiNt. kAt , e-Vc%t... ta,1 aCt\At5 Ntrozkl,At
Contact Name
Street Address
t M; 0!\
City or Towij
Po Box 3aa.1
Mailing Address
• w
, Act\
City or Town
c°00 ) lic\o
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
PC 3%16
Zip Code
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ext
c. WATER LEVEL Below Top of Casing: > ttk
(Use "+" if Above Top of Casing)
FT.
411606
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): V METHOD OF TEST AM
f. DISINFECTION: Type NIA Amount i /#
g. WATER ZONES (depth):
Top 1D Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom Ft. of SG14O /4YC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
i Top 0 Bottom 3
Top ,3 Bottom q Ft. I; 61140n PDdr
Material
Ft. PO / 6j
Method
Po Of
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
�vin
Top g Bottom ) Ft. in. in. firl
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 4 Bottom 15" Ft. , q/ 0 qit,d
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
U
12. REMARKS:
Formation Description
grg WA 1iT 541,0%8
S } 4y Sa.vvi
(rtcy dill 5 0,•%.d
fO' 6 20 lige
0-,f itrr aYi c .,,sing Unit
Alofic .
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECORD HA B EN PROVIDED TO THE WELL OWNER.
0l3
ATURE OF RTIFIED WELL CONTRACTOR D TE
: 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-lb
Rev. 2/09