385356_Well Construction - GW1_20100712

NON RESIDENTIAL WELL CONSTRUCTION RECORD
Norm Caro(rra Department of Environment and Natural Resources-Dlv's,on of Water Quail;
WELL CONTRAC1 OR CERTI ?ICATION i# 2-2..I
Ct
1 WELL CONTRACTOR.
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Well Contractor (Individual) Name
I!%C(oit
Well Contractor Company Name
STREET ADDRESS G 1oQ
City or Town
(io'-t
State
I Vat..
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
Zip Code
L� I�
STATE WELL PERMIT#(dapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Mondonng ❑ Municipal/Public ❑
Industna1JCommercial ❑ Agncullural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED IC)
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION.
CITY iCm COUNTYl,4 <-0 e.
(Street Name, Numbers, Community, Subdimsion, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑Flat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source ID GPS ❑Topographic map
(location of welt 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 SVv t
STREET ADDRESS S i-hrl1/4
City or Town State Zip Code
CONTACT PERSON JE6Ls - Oc9
MAILING ADDRESS
City or Town State
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 1-5
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 IV 0
c. WATER LEVEL Below Top of Casing 0 FT
(Use "+' if Above Top of Casing)
Fy 4
d. TOP OF CASING 1S L I II-- 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 C7
f. DISINFECTION. Type Amount v
g. WATER ZONES (depth)
From To From To
From To From To_.48 25
From To From To
6 CASING. Thickness)
Depth Diameter Weight Matenal
From 0 To 3 Ft 1 x& B6 P v6
From To Ft
From To Ft
7. GROUT. Depth Matenal Method
From 11' To 3 Ft
From To Ft
From To Ft
B SCREEN Depth Diameter Slot Size Material
From 3 To 1 3 Ft t in in Pvt
From To Ft in in
From To Ft in, in,
9. SAND/GRAVEL PACK:
Depth Size Material
From 2 Tod 3 Ft
From To Ft,
From To Ft
10. DRILLING LOG
From To
0 `3
11. REMARKS:
Formation Descnption
lUl_ . 2 N10
i YiU..
tnfOrrlT>�a3G
I DO 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 PR TO THE WELL OWNER
•31.10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
tjJi- L td
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