385353_Well Construction - GW1_20100712

NON ©NRESIDENTIAL WELL CONSTRUCTION RECORD
rf^rh Carobs -a Department of Environment and Natural Resources -Division of Water Quahty
WELL CON a RACT OR CF' RTIF IC 4TIOiat #
1
WELL CONTRACTOR.
KC L_,L)
Well Contractor (Individual) Name
MC(oi1..u��a.5
Well Contractor Company Name
STREET ADDRESS GZ (.c5 B b..7
CI' t) L.( 14Zi L
City or Town State
(tc M )- loot
Area code- Phone number
2. WELL INFORMATION.
SITE WELL ID #{if applicable)
L (s
Zip Code
STATE WELL PERMIT#(rf applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitonng 0 MunicipaUPublic 0
Industnal/Commercial ❑ Agncultural 0 Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 14' IC)
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION.
CITY -+kn COUNTY-1 ,a �6e
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
°Slope ❑Valley ❑Flat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3
LONGITUDE
May be m degrees,
minutes, seconds or
m a decimal format
Latitude/longitude source ❑GPS ❑Topographic map
(location of well must be shown on a USGS fopo 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- ! > ► Am:.
STREET ADDRESS .5
City or Town State Zip Code
CONTACT PERSON E & ww C�s9vi
MAILING ADDRESS
City or Town State
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH: l '
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing in
(Use "+" if Above Top of Casing)
ND
FT
Z2_I/
3 ..s to e�
d. TOP OF CASING IS IL 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) 0 METHOD OF TEST C)
f. DISINFECTION* Type U Amount
g. WATER ZONES (depth) ZC.\
From To From To ONNI
From To From To
From To From To
6 CASING: Thickness/
Depth Diameter Weight Matenal
From O To 3 Ft 1 5C1$Z
From To Ft
From To Ft
7. GROUT Depth
Matenal Method
From 0 To t Ft flc..t- an
From To Ft
From To Ft
8 SCREEN. Depth Diameter Slot Size Material
From 3 Tot 3 Ft t in ' cl in pve
From To Ft, in, in
From To Ft in in
9. SAND/GRAVEL PACK:
Depth Size Material
From 2- Tot 3 Ft b' 3 .5 t 1 % c r,
From To Ft.
From To Ft,
10. DRILLING LOG
From To Formation Descnption
O 1'3 5a-c\
11. REMARKS:
AG
aT r „-.�,
IVIL
reri
k•Z
100 HEREBY CERTIFY THAT THIS WELL. WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HA BEEN PROWa€O TO THE WELL OWNER
'31'to
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 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-lb
Rev 7/05