381086_Well Construction - GW1_20100215

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NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3505
1 WELL CONTRACTOR
Joe Fornecker
Well Contractor (Individual) Name
McCall Brothers Inc
Well Contractor Company Name
6700 Brookshire Blvd
Street Address
Charlotte NC 28216
City or Town State Zip Code
(704 ) 399-1506
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
I cc J69
OTHER ASSOCIATED PERMIT#(if applicable) Ai 1
SITE WELL ID #(if applicable)
N
_ 3 WELL USE (Check One Box) Monitoring E Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation)( Other ❑r (Ii t se)
DATE DRILLED f - I 10
4 WELL LOCATION•
(:fl C3cooKif e PIS, , 732,(6
(Street Name,
,Numbers, Community, Subdivision, Lot No , Parcel, Zip Co Je)
CITY Cr L3� �QFIr COUNTY
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑ Valley ❑Flat pt,Ridge ❑Other
LATITUDE SP3S ra o.27 " DMS OR 3x XXXXXXXXX DD
LONGITUDE ° 5• [4.92. " DMS OR 7X XXXXXXXXX DD
Latitude/longitude source PS pfopographic 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 )
5 pf)_dcx
F cilit Name-c )
Facility ID# (if applicable)
tvct
r'T ° oIEZ
City( or Town
�1 of GoC (1
Contact Nam
9725 �. HD(Iy - (-4U Iv/ i� �icP
M r-rt M- cding A dress
sv; lie ( 2Pc7'
NC Z?21 E
State Zip Code
City or Town State Zip Code
( 7OG) 3 Z6
Area code Phone number
6 WELL DETAILS. a TOTAL DEPTH 72
QI
b DOES WELL REPLACE EXISTING WELL? YES
YES ❑ NO rx
c WATER LEVEL Below Top of Casing �—I FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS t e 5 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) 25 METHOD OF TEST CO If
f DISINFECTION Type (41h Amount ZQZS
g WATER ZONES (depth)
Top 2 2C Bottom Z25 61*fop Bottom
Top 670 Bottom675 op Bottom
Top Bottom
Top Bottom
7 CASING Depth l'• Diameter
Top fir ) Bottom --ZI' 5 Ft t, 0y
Top Bottom Ft
Top Bottom Ft
Thickness/
Weight Mate
ial
8 GROUT Depth - Materi 1
Top 0 Bottom 1(,5 Ft ,C('(�IG/1l"
Top Bottom Ft
Top Bottom Ft
9. SCREEN. Depth Diameter
Top
Top
Top
Bottom
Bottom
Bottom
10 SAND/GRAVEL PACK
Depth
Top Bottom
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
0 /
-lZ
—IZ-/-7Z0
12. REMARKS
Ft
Ft
Ft
Size
Method
i-(c ;e-PUr
Slot Size Material
m
m
in
Material
Formation Description
oven6 fl
9E' 'Cc
krl'15Z010
tnforrratton Processing Unit
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RE s 1 AS BEEN PRO'/I D TO THE ELL OWNER
s,er URE OF CERTIFIED WELL CONTRACTOR DATE
c r-D(nec
PRINTED NAME OF PERSON CONS
RUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev 2/09