381088_Well Construction - GW1_20100215

1 WELL CONTRACTOR
Joe Fornecker
33515
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3505
d TOP OF CASING IS 1 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) fi!`-n.! METHODTOF TEST
f DISINFECTION Type N 11'r Amount
Street Address g WATER ZONES (depth)
Charlotte NC 28216 Top 4CIS Bottom lop
City or Town State Zip Code
( 704 ) 399-1506
Area code Phone number
2 WELL INFORMATION � n
WELL CONSTRUCTION PERMIT# IQOQ -1�1(11 �-I
Well Contractor (Individual) Name
McCall Brothers Inc.
Well Contractor Company Name
6700 Brookshire Blvd
OTHER ASSOCIATED PERMIT#(if applicable) to
SITE WELL ID #(if applicable) N A
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial
'/
/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation® Other ❑ (list use)
DATE DRILLED I- IS- Ja
4 WELL LOCATION•
253o N041(ECcv
(Street Name, Numbers,
Num bers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY CYL F( COUNTY fleck
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑ Valley ❑Flat Midge ❑Other
LATITUDE Q gcj° 2.0, % S , " DMS OR 3x XXXXXXXXX DD
LONGITUDE 1680° S i i LI77 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source QGPS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located )
Facility Na
Street Address
Carr Tor it
FaciIitq ID# b{f a
G.Vt 5 IteOrA
Co�!� en Ccvc
cable)
State Zip Code
Mgt ess
+` (G�
Jvc 22I6
City or Town State Zip Code
6Li- 1699
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES 0
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
1460
NO
FT
Top
Top
Top
Top Bottom
Top Bottom
7 CASING Depth
Top 4 1 Bottom
Top Bottom
Top Bottom
8 GROUT Depth
Top 0 Bottom -
Top Bottom
Top Bottom
elf Ji ?;
C
Bottom
Top Bottom
Top Bottom
Thickness/
D%afneter Weight Material
Ft Ft t /'l1 t k7 PVC
Ft
Ft
Ma rial
Ft bent0414(
Ft
Ft
Method
9 SCREEN Depth Diameter Slot Size Material
Top Bottom Ft in in
Bottom Ft in in
Top Bottom Ft in VVV in
10 SAND/GRAVEL PACK
Depth
Bottom
Bottom
Bottom
11 DRILLING LOG
Top -Bottom
/
/
/
/
12 REMARKS
Ft
Ft
Ft
Size Material
Formation Description
%j
t i V trel 9G� i`!-Q
Mck K
- i5 20
Information Processing Unit
DWQ/bOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCA WELL CONSTRUcTION STAND RDS, AND THAT A COPY OF THIS
RECO HA BEEN PROVIDED'TO THE WE OWNER
SIG RE OF CERTIFIED WELL CONTRACTOR
Joe_Fcf n2_.6 K c
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev 2/09