390191_Well Construction - GW1_20100101

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WE L NTRACTOR �
�' EU7o1/4 (dT (&)
Well Contractor (Individual) Name
T %u -siiw D /l, ,
Well Contractor Company Name
(o teiLly s D140e
fret Address
City or Town O
(433) Sib — C)/10
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
7`A3 3? 411(:,
State Zip Code
'v /A
OTHER ASSOCIATED PERMIT#(if applicable) t'5 / A
SITE WELL ID #(if applicable) "4- P D cc,
3 WELL USE (Check One Box) Monitonng ❑
Industnal/Commercial D Agncultural 0 Recovery ❑ Injection ❑
Imgation❑ Other D (list use)
DATE DRILLED I o"� — 1 --1 0
4 WELL LOCATION
P/t-F teSS, 0i(.J0.-sC
(Street Name, IttGmbers Community, Subcfivfsion, Lot No , Parcel Zip Code)
CITY AR I t) t C. COUNTYYW O cof14 CveF
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope tgalley ❑Flat ❑Ridge ❑Other
LATITUDE SD3S ° `�' 08.10 " DMS OR 3x xxxxxxxxx DD
LONGITUDE &aq `° 3 a.' q 8' tw "DMS OR 7x xxxxx0C00x DD
Latitude/longitude source I3PS Ofopographic map
(location of well must be showy on a USGS topo map andattached to
this form if not using GPS)
5 FACILITY (Name of the business where the well is located )
Facility Nam Facility ID# (if applicable)
a -CO Soo cPVi241.c=
Street Ad ss
A-12-0eic C v`i 87O
City or Town State Zip Code
Contact Name
``-t / 30v C,P d-L p U 6-
Mailing Address
/11-11-0 rAa N C r9- e7 c c(
City or Town State Zip Code
(Raa, (0,q?— S "01 0-7
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES ❑ NOK
c WATER LEVEL Below Top of Casing / 4./ CGS FT
(Use "+" if Above Top of Casing)
qo
d TOP OF CASING IS 0
330191
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) Pi/ A METHOD OF TEST Nl / —
f DISINFECTION Type A f lL Amount
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7 CASING Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
Thickness/
Diameter Weight Material
8 GROUT Depth
Top 0 Bottom
Top 110� Bottom
Top Bottom
Material
16,Ft /Lou
O r Ft jiviON'
Ft
Method
9 SCREEN Depth Diameter Slot Size Material
Top ,3-5
1
Bottom 3/ Ft aK in . C/O in PV G
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
�j Depth s Size Nla_terial
Top oC ° Bottom 3U Ft t a- A ip
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Of / 30I
/
/
/
12 REMARKS
Formation Description
c "t 44S'ti
W &l FM W( / 3 '— 30'
fr, tr.- rt,
tl AIL ,FJ."r�c `C` II =!
DEC 2-2 2010
I. no
Infnr,,., for
I DO HEREBY CERTIFY THAT TH
15A NC C 2C WELL CONSTRU
RECORD 1AS BEEN PROVIDED
i WELL WAS CONSTRUCTED IN ACCORDANCE WITH
PION STANDARDS AND THAT A COPY OF THIS
0 THE WELL OWNER
--- ra -1�- (r)
SIGNA URE OF CERTIFIED W LL CONTRACTOR DATE
EC/ j �r /v rr-I cJ�-•
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
days of completion to. Division of Water Quality - Information Processing, Form2 9-1b
Submit within 30
p 2020ir
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]