413330_Well Construction - GW1_20130513

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4-190& _ A.
1. gkCIZITRACTpr
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Well Contractor (Individual) Namyi
mn, is Nt: tic:
We orltract rCompany e
(5(9g 9 et- Ware
AreettAddress
l kii: l I e
City or Town
(L• 3)
State Zip Code
( ORO) SrSC9 lee)
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT -NW applicable)
SITE WELL ID#(tapplicable) r(LZCI - enc0 `Sits rui
3. WELL USE (Check One Box) Monitoring M' MunicipaUPublic 0
Industdal/Commercial 0 Agricultural 0 Recovery 0 injection 0
Irrigation° Other 0e (list tuese)
DATE DRILLED 4`1(D- 13
4. WELL LOCATION: /e g / �P�
i 0_ VI. �{4lMt Gier/Sal4rt5rchd C7t, Casik `FS
CITY:, 4;t �rrw to l (u SS COUNTY S 1 OW
TOPOGRAPHIC / LANDNSETTING: (check appropriate box)
❑Slope °Valley 'at 0 Ridge ❑Other
LATITUDE 34 a 43 ' "t "DMS OR DD
LONGITUDE n ' i>1tA' 4EOO " DMS OR DD
Latitudellongitude source: (PS ❑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.)
rota eAs4 _ma) n� e. etri% cc
Facility Nameq �f� 6Fppili (applicable)
'T)L rtQG4 � ia•;Al r`r. . (A r o tiro cS
Skeet Address
(Street Name, Numbe , Comm ity, ubdMsion, Lot No., Parcel, Zip Code)
\nei--Sa1J J; L ,A1C, cn940
Gity or Town State Zip Code
Tip (nr MCC(
Con* Name
tu'zR1 (411 1.1
bkiMailing Address
orowl4ea
City
City orTown State Zip Code
(aid) LoctO Pcllr
piC (9g94
Area code Phone number
6. WELL DETAILS: �pprry�
a. TOTAL DEPTH: `TV ®
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO g}o
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
413330
d. TOP OF CASING IS 17 •5 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): = J METHOD OF TEST pulp.
f. DISINFECTION: Type Amount d
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth CIO t9
Diameter Weight Material
Top 4 Bottom 4Ft PIC._
Top Bottom Ft
Top Bottom Ft.
8. GROUT: Depth 9 Material., ser�ial. t Method
Top 4 Bottom 3l FtC^^ tWk Raw t('ttwt
Top Bottom Ft
Top Bottom Ft.
9. SCREEN: Depth, a� Diameter Slot Size Material
Top 3 " Bottom t Ft. .P in. .01.0 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. In. in.
10. SANDfGRAVEL PACK:
Depth Size M.ateA4
Top 33 Bottom LEO Ft. Ik ( .awt
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG.
Top Bottom
/ fC
to/ OS
90 �S'
ac77® rots�{{
S7 Li ti aca
k�.t:1ky
1 P 'yam
t
12. REMARKS: Ef$ORMA71tN PRQCEIOt
r
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS
RECQ$OItAS BEEN PROV@ED TO TH WELL OER.
S``IIGNAARJR`EO,t1FCCER���YY\II)FIEDWELL
.C.OPNT1�(70R DATE
lJ l?1 vtVN t GC
Formation Description
PRINTED NAME OF PERSON CONSTRUCT!
THE WELL
T
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. 2109