413339_Well Construction - GW1_20130426

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 490 _ Ar A 3 J 39
CONTRA R:
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Well Contract r (Indio dual)Nam
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Street Address
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City or Town
(ate) ssa-IWO
W, SSetL'
State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) t e.' RI fitti t) - fttl
3. WELL USE (Check One Box) Monitoring fW timunicipalIPublic 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
inigation° Other 0 (list use)
DATE DRILLED '(' Q�' i3
d. TOP OF CASING 1S ea FT. Above Land Surface*
`fop of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD(gpm): Q r METHOD OF TEST pomp_
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth n Diameter Weight
Top 4 ar Bottom S Ft. s
Top Bottom Ft.
Top Bottom Ft.
Material
8. GROUT: Depth Material ^ Method
Top d)Bottom 1 1-0Ft. q. 4
Top Bottom Ft.
Top Bottom Ft.
4. WELLiLOCATION: pp� d� cc 9. SCREEN:r�1�Depthn Diameter Slott 9S/�iiJze Material
5i L $Q (\jh p G i"i�;(vita ter°'eCLe1 J cic &% \Top_a Bottom C2 Ft�in. _°yd12 in. tW�
(St eetName, Numbers, Communp�, Su ivision, Lot No., Parcel, Zip Code) Top Bottom Ft. in. in.
CITY&Cr5 JJLI 1.0 COUNTY 013s100 Top Bottom FL in. in.
TOPOGRAPHIC / LAND SETTING:
❑Slope °Valley *gat ❑Ridge
LATITUDE 34 ° A(3,
LONGITUDE 77 °G& QS
(check appropriate box)
❑Other
"DMSOR
" DMS OR
DD
DD
LatitudeAongitude source: We; ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form Nnot using GPS)
6. FACILITY (Name of the business where the well is located.)
Q CI Eras-4 tamp- Qra`.se+rsr
Facility Name , (® ,Facility ID# Of applicable)
4. V �ers` a4ce10 Of- �LaFI ;F Sea S4 .
Street Address
06c4fli /i yc aes-gb
City or Town State Zip Code
t !nMoen—
Co Itl `oen-
Co Name
I ed 7$ i41.2e,
Mailing AddressedMC. jtgci
City o1 Town State Zip Code
Lin e gyp
15
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO EK
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
10. SAND/GRAVEL PACK:
Depth Size
Top i g Bottom aZS" Ft.
Top
Top
Bottom Ft.
Material
&MN
Bottom Ft.
11. DRILLING LOG
Top Bottom
—CL_/
/ (O
id / tS-
12. REMARKS:
Formation Desaiption
P,Itraufj 0 ,x siGAir
(al Y
01 tty clynfaci
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION ST 1 . RDS, D THAT A COPY OF THIS
RECO'' BEENPROVI°3t TO THE UE', OWN
SIGNATURE OF caRTIFIED W LnCONTRA `c OR DATE
CS(CUll/
PRINTED NAME OF PERSON CONSTRUITING THE WELL
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-1 b
Rev. 2109