413354_Well Construction - GW1_20130513

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1.wE LL CONTRACT
flbuffl D. Ift
Well Contract (Indivi ual) Name
QI r Ii r II,%al Cc)
W Contrkctor Company me
P y
Street Address
140 Lt*C5iu LL9
City or Town
((Zos) gs"/ - 7e tO
Area code Phone number
2. WELL INFORMATION:
0..J, (gsR
State Zip Code
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED FERMIT#(ifapplicable) .-at
SITE WELL ID #(if applicable) $.a.&I face a1,
3. WELL USE (Check One Box) Monitoring ("Municipal/Public D
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigationo Other 0 (list use) %7
DATE DRILLED q- I -- 0J
4. WELL LOCATION:
(Street Name, umbers, ommunIS
Sub (vision, Lot No., Parcel, Zip CCode),� ,� 6t
CITY`\cA v1 W COUNTY ®goU lesti
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope OValley ❑Flat ❑Ridge ❑Other
LATITUDE 34. °LH' SIB' "DMS OR DD
LONGITUDE 77 "91' CO 4 "DMS OR DD
Latitude/longitude source: rotas ❑Topographic map
(location of well must be shown on a USGS typo map andattached to
this form lfnot using GPS)
5. FACILITY (Name of the business where the wellllliiis located.)
Met NameE�1- Ma I� pFa lb/ I. ff applicable)
slititt
ass-Lt)
State Zip Code
t yd�rewss�.^1+,pt�r�
etr F-a7tJU, `o.Y.
City or Town
City or Town State - Zip Code
( Q/d) a>q0 -9c1Ps
Area code Phone number
6. WELL DETAILS:
a. TOTAL. DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES./ NO ❑
Ir
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS a . S FT. Above Land Surface*
'Top of casing tehfiinated at/or below land surface may require
a variance in accordance-rdwith 15A NCAC 2C .0118.
e. YIELD (gpm): I r o METHOD OF TEST puin ' (3 •
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 ) aTerial
Top et Bottom (J FL 8" let - Lid C'
Top Bottom Ft.
Top Bottom Ft.
8. GRO T: Depth n Material
Top Bottom ®1 Ft.Calilhel
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Stye Material
Top Bottom 1 5— Ft. .79 in. .OQOn. PVC --
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 3 Bottom I �Ft. t4 • l
Top Bottom Ft.
Top Bottom Ft.
Materal l
C.>
11. DRILLING LOG
Top Bottom Formation Description
d / C- Akio) O si
Lti 5'Yd4Y
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CON TRUCTION ST NDARDS. AND THAT A COPY OF THIS
RE .'D BEEN PRO iL ED TOT E LLO !'. R.
SIGN TURE OF CE IFIED ttELL TRAITOR
PTA � COR'�
P TIED NAME OF PERSON CONSTRUCT(
DATE
G THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mad Service Center, Raleigh, NC 27699-161, Phone i [phone]
Information Processing,
Form GW-1 b
Rev. 2/09