385354_Well Construction - GW1_20100712

NON RESIDENTIAL WELL CONSTRUCTION RECORD
l tcrh Carolina Department of Environment and Natural Resources- Dtv's,on of Water Qualify
"WELL CON YRAC1OR CERTIFICATION # 12- I C
1 WELL CONTRACTOR.
KC-L)L) (rico-,n J
Well Contractor (Individual) Name
, i' C(ot►
Well Contractor Company Name
STREET ADDRESS 6-10c'
C1-ma iv _.czi
City or Town State
(Zo-t )- -1 t tSt�L
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
STATE WELL PERMIT#(dapplicable)
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 ❑ (list use)
DATE DRILLED 14' t 0
TIME COMPLETED AM 0 PM 0
3. WELL LOCATION:
CITY iC a COUNTY I3� s-ws,,.,b e_
s0i s \i�\\ o,St
(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 in degrees,
minutes, seconds or
in 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 rf not using GPS)
4. FACILITY -is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITYf��S� taSLs�n�.t �n�QLI�
STREET ADDRESS Sc-►.9\-L•L\ 2,5
City or Town State
CONTACT PERSON - E6t_& -
MAILING ADDRESS
Zip Code
City or Town State
Area code - Phone number
S. WELL DETAILS
a TOTAL DEPTH.
t3
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ N91 ❑
c. WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
FT
5
e"201
LI
d. TOP OF CASING IS 2 I'L ta FT Above n iEursac
'Top of casing terminated at/or below land surface mar =t tl
a variance in accordance with 15A NCAC 2C 0118 11 `t;
e. YIELD (gpm) U METHOD OF TEST C,
f DISINFECTION Type -' Amount o
g. WATER ZONES (depth)
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Matenal
From 0 To 3 Ft I 5cW Pam(
From To Ft
From To Ft
7. GROUT. Depth Matenal Method
From Z To \ 3 Ft Ifx.ti-* I o:- ft> +,--
From To Ft
From To Ft
8. SCREEN Depth Diameter Slot Size
From 3 To \ 3 Ft . in X in
From To Ft. in. in
From To Ft in, in
9. SAND/GRAVEL PACK:
Depth Size
From 2 To \ 3 Ft �' 3
Material
eve
From To Ft.
From To Ft
10. DRILLING LOG
From To
C� \3
Matenal
5t 1 %t_rr
Formation Descnption
"set \
JUL i 2 201i)
, ,mrs UPIt
IntOrmmlat' JP r'v-
11. REMARKS
f3jt,A0-\r `• 'L
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WfTH
15A NCAC 2C WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PR I TO THE WELL OWNER
•3HH l!c
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
tv4t.,4
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-lb
Rev 7/05