413332_Well Construction - GW1_20130513

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4318-A.
AC�R: A f ;
Well Contractor (Individual) Name
Moyle llri1icuq
Well dontractor ompany e
6j(7 g fWl CI(.
t tn�it5ui.ufi
1. R
City or Town
(B ) - taro
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL IDAir applicable) t? Rs W U1- » k
3. WELL USE (Check One Box) Monitoring (j'Municipal/Public 0
Industrial/Commercial 0 Agricultural 0
IrigationD Other 0 (list use)
DATE DRILLED II-11- (;
4. WELL LOCATION: e
rsCt O%p 6i'P('pf rat r5ertr a et to* c rdk
S tName, Numbers, Commll@$�ly', ubdivieton, Lot No., Parcel, Zip Code) �
eV> 3s�f/
State Zip Code
Recovery 0 Injection 0
( pp ), y
CITY: C 1rttg'fl4)vib COUNTY ail610a)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope OValtey teat ❑Ride ❑Other
LATITUDE 34 ° `✓3' $3tt "DMS OR DD
LONGITUDEn ° o. Qi? "DMS OR DD
Latitudefong"dude source: (S Dropographic 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.)
mC l FAck,me6 Cell. t4i.P ('°er.
Faddy Name 1 Fadlity4b# Of applicable)
-Pet-'AU (tit (off t E.t.
�e Address lJ
c\Q-t-C O ZI i 4C aascdo
City or Town
Tct tff lam• mom
contamNarne
Ir-n L
l-(t,UC(
iling Add s (Q1
i'lCity orwn
( Ste) bRo act IS —
Area code Phone number
6. WELL DETAILS: rfl
a. TOTAL DEPTH: 9C)
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO V'
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
State Zip Code
dIr. asgg5
State Zip Code
413332
d. TOP OF CASING 1S C6 FT. Above Land Surfae
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): i .-
f. 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
METHOD OF TEST Q t UA (f)
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth M "al t ethod
Top i Bottom i ( Ft t. : 4
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top I r Bottom 90 Ft q in. . NO in. P ((CC
Top Bottom Ft in. in.
Top Bottom Ft in. in.
10. SAND/GRAVEL PACK:
Depth Size Materiel '
Top 1 S Bottom at FL G.'r,µn(1�
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
12. REMARKS:
Formation Description
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION ST NDARDS, AND THAT A COPY OF THIS
R j�IA�S�BEEN PROYII[tTO El O ,ER.
C� � �C]ll 7
t
SIGNATURE OF CERTIFIED
Tx.)-10 (3
RA OR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
IT
Submit within 30 days m of copletion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-lb
Rev. 2/09