385348_Well Construction - GW1_20100712

NON RESIDNTL.IL WELL CONSTRUCTION RECORD
rtorh Carolina Department of Environment and Natural Resources-Divs on of Water Quaht;
WELL CON; RZCT00R CFRTIFIC 4 T ION # I Ct
1, WELL CONTRACTOR._n _
C iJIJ�\ 1-. t ritOoun�
STREET ADDRESS G—i o(
CktaL
City or Town
rio`-t
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable) i--
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring 0 MunIcipaUPublic ❑
Industnal/Commercial 0 Agncultural 0 Recovery 0 Injection 0
Irngation❑ Other ❑ (list use)
DATE DRILLED lc)
Well Contractor (Individual) Name
Well Contractor Company Name
State
SW..
Zip Code
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION:
CITY +ka COUNTY I ►-w . a
-Sr kkkkl
(Street Name, Numbers, Community, Subdivlston, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑Flat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3
LONGITUDE
Latitude/longitude source: ❑GPS
May be in degrees,
minutes, seconds or
in a decimal fomiat
❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. FACILITY• is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY- �S� t i, le.r cc,L.,t
STREET ADDRESS S \-.-t\1/4 Q .
City or Town State
CONTACT PERSON OA .�
MAILING ADDRESS
Zip Code
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH ' 9 . L
b. DOES WELL REPLACE EXISTING WELL? YES 0 R44 0
c. WATER LEVEL Betow Top of Casing 0 FT
(Use "+- if Above Top of Casing)
d TOP OF CASING IS -2--t IL FT Above Land Surface*
°Top of casing terminated at/or below land surface mawire
a vanance in accordance with 15A NCAC 2C &Ai
e. YIELD (gpm) 0 METHO F�rE T E. \ \,
f DISINFECTION Type ® AnZkin l;Li►
g. WATER ZONES (depth) �®
From To From To
From To From To
From To From To
6 CASING. Thickness/
Depth Diameter Weight Matenal
From, — To* Z Ft l SCkY- . P„ c
From To Ft.
From To Ft
7. GROUT. Depth Matenal Method
From 0 To t Ft �.t9 Ft �„>, .`
From To Ft
From To
6 SCREEN Depth
FromM, 2 To t ct 2
Diameter Slot Size Material
Ft t in Zo +n P i c
From To Ft. in
From To Ft in
9 SAND/GRAVEL PACK:
Depth Size
From 3. Ch. To IctiL Ft u
From To Ft,
From To Ft
10. DRILLING LOG
From To
0 (9.z
11. REMARKS
In,
In
Material
k 1►c;,
Formation Descnption
'Sc t
aU, 2
,;trig Unit
Intocma"uis,iniBOG
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PR01 5O TO THE WELL OWNER
SIGNATURE
OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-lb
Rev 7/05