382344_Well Construction - GW1_20100409

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NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2-QS 6
1 WELL CONTRACTOR_
Well Contractor (Individual) Name
Aeo4 x w, Div C
Well Contractor Company Name
_190ge NOj27ffpc )
Street Address
ZS7o 7
City crr Town
State Zip Code
( e.3) Sq 3' - 2 Pc)
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#_T
OTHER ASSOCIATED PERMIT#(if applicable) 70c,013
SITE WELL ID#(ifapplicable) /43 1
3 WELL USE (Check One Box) Monitonng Ig Municipal/Public ❑
IndustriallCommercial ❑ Agncultural 0 Recovery ❑ Injection 0
Imgation0 Other ❑ (list use)
DATE DRILLED - t g - I O
4 WELL LOCATION
70 Co GA-s-rwAy D2(uC 2 ' ZOS'
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY
d TOP OF CASING IS FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
YIELD (gpm) METHOD OF TEST
DISINFECTION Type Amount
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Wei�jht' {Material
TopBottom Z Ft Z *� 7� f
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom I Ft 764-41.1 CCU ?:),
Top ( Bottom I- S Ft rienl.-'Acts o,-''
Top Bottom Ft
9. SCREEN Depth
Top Z Bottom 0-
Top Bottom
C 1"-4T -Oi7C COUNTY P/ cLOV YDco(OTop Bottom
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope DValley ❑Flat
LATITUDE " DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source ❑GPS [Topographic 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 )
RoP.-sn Q mfAJQr r A) CLE � S
Facility Name Facility ID# (if applicable)
3c3c,O ecs-ti j ''i.c
Sheet Address
❑ Ridge ❑ Other
(cam NC
City or Town
T4 e - frT?C 0 -frrc
Contact Name
'34)1?-A 7/2441)-- OA24
2r2C
State Zip Code
A-SScx�A-7� S
Cod 2--7
Mailing Address
C141426tn7 C 2 Fit 7
City or Town State Zip Code
( 704-) 525- ?too
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH % Z
b DOES WELL REPLACE EXISTING WELL? YES ❑ Ii9
c WATER LEVEL Below Top of Casing FT
(Use "+" if Above Top of Casing)
e
Diameter
Ft 2 in
Ft in
Ft in
Slot Size Material
O.010 in (�O-
in
in
10 SAND/GRAVEL PACK:
Depth Size Materi}l
Top i Bottom 12- Ft Oa- - end
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
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12 REMARKS
t:, ,
A
- ,stn Unit
r,,winiFtOG
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 HAS BEPR PROVI Il D TO THE WELL OWNER
i/(ef (O
SIGNATURE OF CE IFIED WELL CONTRACTOR DATE
4771.E SPe--ac
PRINTED NAME OF PERSON CONSTRUCTING 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