382328_Well Construction - GW1_20100409

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # agSP
Well Contractor (Individual) N
Well A52kwontractor Company
STREET ADDRESS 9O8g uriqielatr.
City or Town State
(10.3_)- 5 - a,l $4
Area code- Phone number
2 WELL INFORMATION 1L
SITE WELL ID #(I( applicable) SAQ��!!'' ! i
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring I. Municipal/Public 0
IndustriaVCommercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED _7 - � Id
TIME COMPLETED /fryBe) AM M'J PM ❑
3 WELL LOCATION'
CITY LCOUNTY
ag7o7
Zip Code
/a//4 !t,e.d L4—•,i
(Street Name, Numbers Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope :Walley (Vial ❑Ridge 0 Other
(check appropnate box)
.5/1-
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source ■GPS oTopographic map
(location of well 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/
STREET ADDRESS //e/ /D
e774tc ,
City or Town
CONTACT PERSON /
M&G A D ESS
City or Town
4 ft )- SFl
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES 0 NO 111
State
4 aO7
4'L
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
FT
3112 sx
�_ cs ..v C
d TOP OF CASING IS • FT Above Land Surface'
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) Wfa. METHOD OF TEST
f. DISINFECTION. Type P CE.,„
g WATER ZONES (depth)
From To From To
From To From To
From To From To
Amount
6. CASING: Thickness/
From D OToth Ft Di�T}r�er s'C [ 9ha ��t f a�
From To Ft �! �/
From To Ft
7, GROUT' Depth Material ,� Method
From 0 To �,,2 Ft / d l!/`
From
From
8, SCREEN:
To Ft
To Ft
Depth Diameter Slot Size �O�MMattee'nal
From To Ft J in 40 in V_L_�
From To \ Ft in
From To
9. SAND/GRAVEL PACK:
Fronk To
Ft in
in
in
Size Material/
Ft A`.,-,/A.!/d
From To Ft
From To Ft
10. DRILLING LOG
From To
0
Formation Description
r 07
yr-a1 F�4
'
3 9 201Q
:cr-n Urea
Intormat,06,
11 REMARKS. DWOIEC G
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wmi
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HASIDED TO THL WELL OWNER
IGNNATURE OF TIFIED
PRI SITED NAME OF
ELL CONTRACTOR DATE
RSON 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 568.
Form GW 1b
Rev 7/05