413333_Well Construction - GW1_20130513

1. WCO`N�TR,A1CTQftt: arta
rirell Contractor (Indiviviiidual) Name
Well ctor Company Na
eel Address
i 1�l*E-5Vi11.1.
City or Town
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4908 -A.
d. TOP OF CASING IS a ''S- FT. Above Land Surface`
'Top of casing terminated at(or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
(asp) O -mob
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(ffapplicable) ®�� HA
SITE WELL ID #{ff applicable) 1= tiW V aAu4 - < 9 9 vu
3. WELL USE (Check One Box) Monitoring MMunicipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
InigadonO Other 0 (list use)
DATE DRILLED M-l% -
4. WELL LOCATION:
kr. f6'j
State Zip Code
Ai%$C: /Q,, &P CtiPrrt .Irdtc'J'4K (Tao 6; Off`•
(Street Name,jNNumbers, Comn,,AalFly, Subdivision, Lot No., Parcel, Zip Code)
CITY1JOCtSo1iU6� COUNTY cs4dwi
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
oSiope oValley nF(at Ridge ❑Other
LATITUDE 34 ° 93 ' � 1,� " DMS OR DD
LONGITUDE77 ° a(1). (1le "DMS OR -DD
Latitudehongitude source: ES ❑ropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
of t Fk5-L. W.L
Facility Name
Td4wrrs.dia0 &:.
ctree[Address
JCsCk4lllYZ vQ.
City or Town
Mitt Matt-
Conte
Name
14-11 in iling t�W i l 1-t
Add ss (!
Ccutp. &i r
,g Fa ID# (if applicable)
Lp CH/Ct ?kb sd.
M
City or Town
( Rib) tgctC)-a9IS—
Area code Phone number
5. WELL DETAILS:
a. TOTAL. DEPTH: 40
0-85-40
State Zip Code
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES t/NO ❑
c. WATER LEVEL Below Top of Casing: FT.
(Use "+n if Above Top of Casing)
e. YIELD (gpm): t ° S—
t DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
l6 BottomS Ft. 9 410 Wc_
Ft
Ft.
s13323
Top
Top Bottom
Top Bottom
8. GROUT: Depth a
Top 4 Bottom 3�
Top Bottom
Top Bottom
METHOD OF TEST rtllut'p •
Material
Ft. G2!nCLNetk-
Ft.
Ft.
Method
tit -oaks -t
9. SCREEN: Depth Diameter Slot Size Material
Top .3S' Bottom t-lo Ft in. .0 D in. plc -
Top
Bottom Ft. In. in.
Top Bottom
Ft. in. In.
10. SAND/GRAVEL PACK:
9 Depth Size
Top 33 Bottom NO Ft. %4 t
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
ci s
10
to / It
/
as-/
30/
/
/
/
12. REMARKS:
Materal
5
Formation Description
KNOW.) °tap a1 [4-
MAY - 3 ZU13
16","
INFORMATION PRO
MAV 13 2013
CTION
SING UNIT
1 DO HEREBY CERTIFY THAT THIS WELL,WAS CONSTRUCTED INACCORDA
16A NCAC 2G WELL CONSTRUCTION STAKIARDS AND THAT A COPY OFT
RECORD UAS BEEN PRO 1714EDTOjTH$ WELLCjWNER:--
WITH
Agab
SIGNATURE OF CTIFIEUWE CONTRA TOR DATE
P D NAME OF PERSON CONSTIjJCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, MC 27699-161, Phone [phone]
Form GW-lb
Rev. 2/09