413338_Well Construction - GW1_20130513

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # [Y "k
Street Address
t-tuai bv:
City or Town
(a5fa) fr5o"i-O
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL IDAir applicable) re- - I(Itd1 - Sat 91A�
1. WELL CONTRACTORfA�
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Well Contractor (Individual) Name 3
Mec`` o:SiIAA C0
Well Contrator Company Name 1/41
ISIP 1.1,420 4- C.ke
State Zip Code
3. WELL USE (Check One Box) Monitoring [j AunicipauPublic 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Inigation0 Other 0 (list use)
DATE DRILLED
4. WELL LOCATION: p ( 9. SCREEN: Depth
5(bt. Wk Qauli'st.t ✓' Jra%rrss('Ji.s t$&°*e^SLTop ,Z,CBottom N.0
(Street Name,ANumbers,ACopmm dy, S bdNision, Lot No., Parcel, Zip Code) Top Bottom
CITY:S Al(' s(b hL O COUNTY 0&6
TOPOGRAPHIC / LAN SETTING: (chec( appropriate box)
❑Slope [Valley lat 0 Ridge ❑Other
LATITUDE 34 °g3'85c( "DMS OR
LONGITUDE 77 °,2(a. ` .3? ° DMS OR
Latitude/ongitude source: l PS Dropographic 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.)
Wtet e* --Mr /e,�91p ar .
Facll' Name Fa ID# (if applicable)
ZN L+fk0 t . Loft^NAL� celA St,
DD
DD
Address
k �t),(L9 tic flS
City or Town State Zip Code
Contest Name
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Mailing Address
G/a®skec{ f'l �- ifl't13
dy or own State Zip Code
(9rv) (A'®-&StC
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: C1O
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOVA
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
n 1 3338
C®
d. TOP OF CASING IS 9 " o 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): 1 v METHOD OF TEST p (i((((y%
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
Bottom
Bottom
Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top Cb Bottom .fi� Ft. .1r,
Top Bottom Ft. o�
Top Bottom Ft.
8. GROUT: Depth Material Method
Top .4 Bottom 3 1. Ft. LLtM4k li2u 1� a sta �9
Top Bottom Ft
Top Bottom Ft.
Diameter Slot Size
Ft._. in. ,01fi in.
Ft. in. in.
Top Bottom FL in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 33 - Bottom CI® Ft 1 (
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
/ s
/
12. REMARKS:
Material
w
Materiel
sotto
Formatlon Description
1 -
W
yyA uinsystalot
to MATIou PFUukssJNU 1
Ia
I DO HEREBY CERTIFY THAT THIS WELL WAh SNSTRUC(ED.INACCORDANCFSNfH
15A NCAC 2C, WELL CONSTRUCTION ANDAR ° , AND THAT A COPY OF THIS
R ea;e BEEN PRO .;y,, TO HEI LL0 ER.
SIGNATURE OF CER IFI r CONT
NTEDNAM1 i pL�
N1ED NA1G1� OF PERSON CkRUCT1N
49-1<3
TOR DATE
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-lb
Rev. 2/09