413334_Well Construction - GW1_20130513

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # `fig'- A.
1. CONTRAC 12
) t c uL t
Well Contractor (Individual) Name
(G,tnr 1,
�194
sheet Address
i%w�• Irtl�, OJ. 3$ t1p
City or Town State Zip Code
( 9LSID) Ls Se-1 OOd
Area code Phone number
2. WELL. INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID IMF applicable) (tract tn() - ((s G Liu
S. WELL USE (Check One Box) Monitoring @�Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery ID Injection 0
Irrigaiono Other 0 (list use)
DATE DRILLED '1- t& ( 7,
4. WELL LOCATION:
Ath ii(\aAp Cita.(e /�,.dto& cocLeJo(.tot "slit._
(Street Name, Numbers, Comm Subdivision, Lot No., Parcel, Tip Code)
CITY:<�(' dt.SOPJ Ltd COUNTY CASSIA
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ElValley Cleat 0 Ridge ❑Other
LATITUDE 34 "'i3' �1' $ "DMS OR DD
LONGITUDE 77 "&tp' RR - " DMS OR DD
Latitudehongitude source: EstsS ❑topographic map
pocation of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.)
MCA ens#, crap Cnu e • ('r(e er
Facility Name Fa itytIC* (ifa licable)
rell-trcer ofiri e (p^ c q `• •
Street Address
Sat h.sou V=EL•o
City or Town
TrttlAr 11'ber't
Conte I14-nt-1 t-lwu Fi
M ilingAddre s a��3
I Pon r,
City or T Sfa a Zip Code
( 4(0l (AD -a0.t'
Area code Phone number
6. WELL DETAILS: CIO
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES i e NO ❑
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
Well tractor ompanyN
CAd .
N6
ass'-1Q
Zip Code
113332
d. TOP OF CASING IS a • 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): t ' ' METHOD OF TEST (pWA?
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top Bottom 440
Top Bottom
Top Bottom
8. GROUT: Depth
Top Bottom 3.
Top Bottom
Top Bottom
Thickness/
Diameter Weight aterial
Ft. ea0 r• �A:.V\ ^t(i �V d
Ft.
Ft.
Material Method
Ft. Calk& ( em. ` 1/2uu. t
Ft.
Ft.
9. SCREEN: Depth Diameter Slot Size
Top 35 Bottom 40 Ft. pi in. .6(® in.
Top Bottom FL
Top Bottom
Material
PVC --
in. _ in.
Ft. In. in.
10. SANDIGRAVEL PACK:
Depth Size
Top 35 Bottom 40 Ft. W 1
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
.I t0
ID lS
35-1
2Q
Material
c�OL
Formation Description
1
12. KS 4A 1 1 3 2013
Af
1.e: trr
MAY ®3 2013
WATER QUALITY SECTION
FORMATION PROCESSING UNIT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDA THAT A COPY OF THIS
RPRO lTO TH WELL ER.
SIGNATURE OF CERTIFIED ELL 7 CTOR DATE
c5e.uni P- Gad -
PRINTED NAME OF PERSON CONSTRU
NG 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