413151_Well Construction - GW1_20130429

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NONRESJDENT!AL WELL CONSTRUCTION RECORD
North Carolina Department of Environrtxnt and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
1. WELL CONTRACTOR:
Wets ConWctw (Individual) Name
trXell Contractor Company Name
":71- CA 1 (A.). - I
Street Address
e 1 ��''� ram' I�' •`'
City or Town
Lie2
t.
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT$
fe;)
f. DISINFECTION: Type ,._._. Amount
• g, WATER ZONES (depth):
c.sazi
• Ir+tBottom., Top Bottom
413i5i
d. TOP OF CASING M I F T.
• � -- Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCK 2C .0118.
a. LLD (gym): , 60 METHOD OF TEST
__r_w_e_r-
State
Cade � •
TOp Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
r. CAS/NO: Depth Diameter Weight Malarial
Top Bottom & Ft. "� Vi
too -
OTHER ASSOCIATED PERMIT9{rr app icetMe)
SITE WELL ID Aj oppiio e
3. WELL USE (Check One Box) MontbrIng Ca MunicipaUPubllc 0
IndustrialCOmrnercial 0 Agricultural 0 Recovery p Injection 0
Irrigation° Other Q fiat use)
DATE DRILLED ,_r(P)
4. WELL LOCATION:
P) I
(Street Name, Numbers.
tom
. - - . s La No.• , Zp6 Coat)
Cam: J► couNri
TOPOGRAPHIC r LAND SETTING: :heck°. xppnoprile boat)
O Siope 0 Vey► O Flat 0 Rk1ge Other
lATITUbE 1 , OMSOR3x.DD
LO�tip la 3 DMS oR DD
Latitude/longitude source: 40PS Qropographlc map
(location of well must be shown on a USGS Apo map endattachecr to
this form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
Facikty Name
Street Address
City or Town
Contact Name
Facikty IDS (If applicable)
State Zip Code
01
Melling Address
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing; r
(Use '+• If Above Top of Cosine)
TopBottomFL
Top-• BottomnFt,
: 8. GROUT, Depth Material Method
Top ( Bottom i Ft. /Iuk"45 fd'
Top Bottom
Top__ BottomFt;,,,_,_
8. SCREEN: Depth Dsrwtdr Blot Size Material
Too, _ Bottom W Ft, / i In. Ole , i.,Je--
TOD
ToP-
--- Bottom Ft. In. In.
: 10. SAND/GRAVEL PACK:
Depth Stu Mail
Top Bottom Ft.
Top 8o Ft.
Top Bottom FL
: 11. DRILLING LOG
Top Bottom Formation Description
1_41° - 5s-i
12. REMARKS:
Do HEREBY CERTIFY THAT TNr9 WELL WAS CONSTRUCTED rN ACCORDANCE WITH
15A NCAC 2C, CoNSTR • STANOARors, m o THAT A COPY OP THIS
RECORD - • .: TO THE WELL. OWNER.
SIGNATURE O0CERTIF 0 WELL COLT w
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
5'71 —13
DATE
Submit within 30 days of completion to: Division of Water Quality - inforrr►ation Processing,
1617 Mali Service Center, Raleigh, NC 27699-161. Phone :[phone]
RECEIVED 04-21-' 13 20:17 FROM- 9103133102 TO- NC DENR P&S
Form CW-1 b
Rev. 2/09
P002/012