412535_Well Construction - GW1_20130408

NFNRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3162-A
1. WELL CONTRACTOR:
Walter Lea Davis
Well Contractor (Individual) Name
3D Environmental Investiaations L.L.0
Well Contractor Company Name
2157 Mocksville Hiahwav
Street Address
statesville NC 28625
City or Town State Zip Code
(704 ) 657-7785
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(If applicable)
SITE WELL ID #(if applicable) OW 1C IIZ-/
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation0 Other (list use)
DATE DRILLED 3- /3- 13
4. WELL ULOCATION:// p �/
my Gum ✓A.e,4 4m
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: TA( krdnu /1 c COUNTYpnh'v ti'"
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36 " DMS OR 3X.MCO00000C DD
LONGITUDE T5 " DMS OR 7X,)000 00000( DD
Latitude/longitude source: ❑GPS Qropographic 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.)
/
(A-r0Ir'nCD P.00rinf) d' 4U4c✓ItA1
4.
Facility Name Facility ID# (if applicable)
( I 1 L( %v w1 &fenC, 4 o_
Street Address
SAClcs(,M/d 14-
iU�
C�v or Town /- State Zip Code
apes" ruf/ nvut'nr 13ahnl )
Contact Name
967 .S &v( AVE"
Maijing Address
,lOA/1"
City or Tann
( 9fb) 35'—'f4'57
Area code Phone number.
6. WELL DETAILS:
a. TOTAL DEPTH:
,2299(0.1
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES V NO ❑
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS D 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): METHOD OF TEST
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 0 Bottom a Ft. Seh Vo 4G
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top b Bottom 't% Ft.
Material
con at, 94—
Top Bottom Ft.
Top Bottom Ft.
Method
rmr
9. SCREEN: Depth Diameter Slot Size Material
Top t/v Bottom /4, Ft. 2 in. A/O in. /vct.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top .5� Bottom /6
Size Material
Ft. 0.2 C.¢n cl
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
/
/
/
/
12. REMARKS:
Formation Description
MAN 2 t z013
WATER QUALM SEC PION
miF. mo»Pt:!U N PROCESSING 1)(4i+
EC El E
DO HEREBY CERTJFY THAT IS WELL COa$R G4b}v akUDAW
15A NCA 2G, WF.}L CONST CTI( 3 DS, AND THAT A COPY OF TH
REC(/R HANPR D TO OWNER.
ITH
SIGNATUhE OF CERTIFI, WELL CONTRA TCR - ODATE
/�a4 ��C✓ / Avis
PRINTED NAME OF PERSON CONSTRUCTING 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