385349_Well Construction - GW1_20100712

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NON OIV RESIDENTIAL WELL CONSTRUCTION RECORD
jerk Carohra Department of Environment and Natural Resources -Dives on of Water Quah
WELL CONTRA.C1 OR CERTIFIC ATION # Z 2 1 Ct
1 WELL CONTRACTOR,
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Well Contractor (Individual) Name
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Well Contractor Company Name
STREET ADDRESS 6rlUQ
City or Town State Zip Code
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Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) L & 3
STATE WELL PERMIT#(d applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitonng 0 Municipal/Public 0
Industnal/Commercial 0 Agncultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED S 14' lc'
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION.
CITY -.►..ACe COUNTY1 4.' �b e
i . lkAlA. Q .
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑FIat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
m a decimal format
Latitude/longitude source ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4 FACILITY - Is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY t >
STREET ADDRESS '5
City or Town State
CONTACT PERSON Or9
MAILING ADDRESS
Zip Code
City or Town
State Zip Code
Area code - Phone number
5 WELL DETAILS:
a TOTAL DEPTH
6.5
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOV)
c. WATER LEVEL Below Top of Casing rI FT
(Use "+^ if Above Top of Casing)
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d. TOP OF CASING IS ZI f 2 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) U METHOD OF TEST 0
f DISINFECTION. Typo Q' Amount 0
g. WATER ZONES (depth)
From To
From To
From To
6 CASING.
From To
From To
From To
Depth Diameter
From To (D. 5 Ft
From To Ft
From To Ft
7. GROUT. Depth
From 6 To Z
From To
From
8 SCREEN.
From(o• S
To
Thickness/
Weight blatt0711
1.413(
as
Matenal Method
Ft �atw.Q
Ft
Ft
Depth Diameter Slot Size
To 26•' Ft . In
From To Ft, in
From To Ft in,
9. SAND/GRAVEL PACK:
Depth
From4l To21o•t Ft
From To Ft
From To Ft
•d in
10 DRILLING LOG
From To
Cam' D_6,S
11. REMARKS
Size
U.3
In
in
Material
Material
'Sale -a
Formation Descnption
'bit
,-,...na Unit
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100 HEREBY CER11F/ THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PR 4UIBED To THE WELL OWNER
�'31' 10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
ktN4..41L twt4b.,,
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 668.
Form GW-1b
Rev 7/05