413353_Well Construction - GW1_20130513

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carotins Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # K9C -
Well Contractor (Individua Name
�/i•�tw� Or Cj4J/ltI.V CC)
WeMContra or Companyme
15(o A Soor 4-
Street Pildress
gatitti,(/0
Clty or Town
(d s(.9 ) 85V -70CA
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(irapplicabte)Ze.•W 4i& S'CI IC//1
3. WELL USE (Check One Box) Monitoring ®Municipal/Pubiic ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
lrrigationn Other ❑ (list use)
DATE DRILLED 41-17-(3
1
4. WELL LOCATION:
(SSl? Otto
State Zip Code
53e 89Qz Ct`-11aprn aaJor r 5f
(Street Name, Numbers, munity, Subdivision, Lot No., Parcel, Zip Code)
CITY: OCK$]M141I 9 COUNTY Coda/®
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope oValley ❑Flat 0 Ridge DOther
LATITUDE 34 •413' "DMS OR
LONGITUDE 77 ° 4 ' 99-2 " DMS OR
DD
DD
Latitude/longitude source: I 'S plopographic map
(location of well mast be shown on a USGS topo map andattached to
tbisform if not using GPS)
A5.. FACILITY (Name of the
bbuusineess-/s(�jwhhere the well is located.)
Ap
,r' acir N ` *r /'69 or i d applicable)
f4 rrn Sett'
' cS
etAddress
r l r _9ctirvi (/
AC. a85
City or Town M- State Zip Co e
Co`,` r
it/ QV/TAW
ys a
(QCi�t / )T a alb
Area code Phone numberR /� 6. WELL DETAILS:
a. TOTAL DEPTH:
vV3
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Below Top of Casing_ FT.
(Use "+" if Above Top of Casing)
4 3353
d. TOP OF CASING IS 2 ° J FT. Above Land Surface*
*Top of casing temilnated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm)' I .r METHOD OF TEST pump
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top E Bottom Alter Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
Top to Bottom Ft a
Top Bottom Ft.
Top Bottom Ft.
Thickness/
Weight Material
Pvc
8. GROUT: Depth Mate "al , Method
Top eta Bottom 51 Ft. ' r.! 7 r[Q(s/ t-
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Top as- Bottom go Ft. ec in. ,eaka in.
Top Bottom Ft. In. _ in.
Top Bottom Ft in. In.
Material
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bosom Ft.
Top Bottom Ft.
11_ DRILLING LOG
Top Bottom
4 / s-
./ i]
qv
/
/
12. REMARKS:
Formation Description
A
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCA 2G WELLCONSTRU ON ST' r'"' DS, • THAT A COPY OF THIS
BEEN PROMO THE,ll.,OWNE
SI
PRINTED NAME OF ` ERS• ' CONSTRUCTING
thain
DATE
E WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone r [phone]
Form GW-lb
Rev. 2/09