390195_Well Construction - GW1_20100101

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # '10 1
RACTOR
t IN _ fAJ/Z4 C�..
Well Contractor (Individual) Name
"flu -S7`/- E Pi'Gd6(dNj
Well Contractor Company Name -
(o Fiz AS N-' DAICS 0 ll
Str t Address
City or Town
( 49Z) alb --©i'lt
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# /V// l
•T/)
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) 1'- P A 11" / t2
3 WELL USE (Check One Box) Monitonng@k Municipal/Public ❑
Industnal/Commercial 0 Agncultural ❑ Recovery ❑ Injection ❑
Imgation❑ Other 0 (list use)
DATE DRILLED t oZ " —TO
4 WELL LOCATION
?R OG) -s& A. 97 .467054.
(Street Nhfne Numbers, CommunliY, Subdivision Lot No , Parcel, Zip Code)
CITY AP-0 EN /d C COUNTY&11 G061- 67e
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope Viyalley ❑Flat ❑Ridge ❑Other
^� w ��
LATITUDE as3S ° o'er ' Ai0 lV "DMS OR 3X XXXXXXXXX DD
�
LONGITUDE 01,' 33'• j3 " W " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source kbPS pTopographic map
(location of well must be sho n on a USGS topo map andattached to
this form if not using GPS)
5 FACILITY (Name of the business where the well is located )
?(io1, s Fn,31
Facility Name
ao-p/ 30a Cpd- L D IUtJC
Street Address
Alt oeiv
City or Town "
Ri`
Contact Name
seo L
Marling ddress
AL c-AJ /U-C-
City or Town State
(8A)) <22? - 5.)07
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
Facility ID# Of applicable)
p A.0v
State Zip Code
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ VItiK
q/
c WATER LEVEL Below Top of Casing ('�6S .' FT
(Use "+" if Above Top of Casing)
d TOP OF CASING !SR
go,
3 O195
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) N`i4 METHOD OF TEST AY/
f DISINFECTION Type N!%9 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 Bottom Ft
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 L Bottom 3 ! Ft 6M1t * J 641/i "(->l
Top 4"l Bottom 3' Ft 13674 ^tl 6'4—L p-'f-/
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Matenal
Top 5.5 Bottom (0.51 Ft 9A in 'NO in P V �
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size
Top Z Bottom (As 7 FtOZ
Top
Top
Bottom
Bottom
11 DRILLING LOG
Top Bottom
/ 3`
3i / Cei
12 REMARKS
Ft
Ft
Material
Formation Description 1
&owa3 ' /y �+9 1i7 i'"/ i^llvt/
w0 t . e
S'rltly Fr hu %n-+-tr+ - t 1 V now •)
/4 (66--� ¢v.&e9-/ / c),5
UEC 2 2 2010
I DO HEREBY CERTIFY THAT THIS WEL
15A NC 2C WELL CONSTRUCTION
RE CA HAS BEEN PROVIAED TO T
vs , ,,,��,�. • s'.1c-C1Ind
�i rrnnr-.rr,.,.,.
WAS CONSTRUCTED IN ACCORDANCE WITH'llt
TANDARDS AND THAT A COPY OF THIS
WELL PIER
SIGURE OF CERTIFIE'WELL CONTRACTOR DATE
Uio g• iN-R-t
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-1b
Rev 2/09