413329_Well Construction - GW1_20130503

N ON RESIDENTLIL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # '-RIFS-,
1{.CONNH CR:
zi
Well Contractor fflndivldual) Name
Well mra rCompanyNa 6pe
(St: (1 Jrv,(\ry'1 Ccr,
t A dress
I4LAkACt).11�
City or Town
1606
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(wapplicable)
SITE WELL ID #(irapplicable)t 4• sSct Wu- flul
3. WELL USE (Check One Box) Monitoring [ 4unicipal/Public 0
IndustriaUCommercial ❑ Agricultural 0 Recovery ❑ Injection 0
Inigationo Other ❑ (list use)
DATE DRILLED 4 `i 1 - 13
4. WELL LOCATION: / / g
3 %e $OtG r- C '-(per^ Irsit'arcorL'f)A1 s1( (./kb `8th S�•
A p ri a
(Street Name, NumbeiS, Comb1 ®Inity, Subdivision, Lot Na, Parcel, Zip Code) 1
CITY: 3eires itlltd 4 COUNTY OAS left)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope oValley VIM 0 Ridge ❑Other
LATITUDE 34 "DMS OR OD
0
LONGITUDE 77 "al' S "DMS OR DD
Latitude/longitude source: PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this Pone if not using GPS)
6. FACILITY (Name of the business where the well is located.)
rytr t FAs4. MCP, Coup- G-it vir
Facility NameFaddiltty IDS/('if applicable)
l464.r ectfell.) Ci. loth run,' Si
Street Address
c .prtScouttD
City or Town
T— lf1'cYl( A
Co Name
i y-rt-r (-(-u l
i in Ad
ty
(qIo) (ocio,ac0C
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO igle
Tess
(. ,acidr 0
fate Zip Code
own
r
M 1 g d
( 4PcJ
Ct d
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
�c. ass4p
State Zip Code
Ars asddt3
-State Zip Code
FT.
4,1.3329
d. TOP OF CASING IS a ' J 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 (gam): fl : r METHOD OF TEST pump •
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
Top (p Bottom Lb Ft _ <Ain "AJ PIC -
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top CA Bottom 31
Top Bottom
Material ,( Method
Ft.ct,uut /gad T"lMA i t
Ft.
Top Bottom Ft.
9. SCREEN: Depth ` e Diameter Slot Size
Top 3C Bottom 140 Ft 4 In. . t110 in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Material
QVL
10. SAND/GRAVEL PACK:
Depth a� Size
Top 33 Bottom go Ft. tt
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
_CIL/ 5"
iC / IS
i
/
12. REMARKS:
Material
Formation Description
.5.
MAY-321113
WATER OUAI ITV SECTION
INFORMATION PROCESSING UNIT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 22C, �WELL CONSTRUCTION ANDARD'. AND THAT A COPY OF THIS
REC� Ji�1ISNt..IN PROy$EDTO HE 8 LLO ER.
'i �Jt '('J 4r"e
SIGNATURE OF CERTIFI ^r WELL CQ TOR ATE
1RQA) P V
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
3
Submit Within 30 days of completion to Division of Water Quality - Information Processing,
1817 Mail Service Center, Raleigh,NC 27699-181, Phone: [phone]
Form GW-lb
Rev. 2/09