382331_Well Construction - GW1_20100409

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2,Z5h
1 WELL CONTRACTQR
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Well Contractor (Individual) N
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Well Contractor Company Name
STREET ADDRESS qos$ Jtor. 4ielatr.
City or ownState
fO��State/� %Zip Code
Area lTl l� code- Phone number' 8 �—• SI4 /2
2 WELL INFORMATION'
SITE WELL ID #(if applicable) Stab 79,....77 re /X.
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(If applicable)
WELL USE (Check Applicable Box) Monitoring ! Municipal/Public 0
IndustrtaVCommercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 3 — ( - /Q
TIME COMPLETED
riO
AM($' PM 0
3 WELL LOCATION'
J�_ �y�� ,,��
CITY rim. C[. COUNTY %%4P.1'aC.
//p m eu rt
(Street Name Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
0Slope OValley IIIFIat ❑Ridge 0 Other
(check appropriate box)
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 I not using GPS)
4 FACILITY is the name of the business where the well Is located
FACILITY ID #(if applicable)
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City or Town State
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CONTACT PERSON /y��"R�'[��
M%�LI GAD ESS
City or Town State
Oa a
NAME OF FACILITY
STREET ADDRESS
4 cL )- S,�l
Area code • Phone number
5 WELL DETAILS
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES p NO ■
c WATER LEVEL Below Top of Casing FT
(Use "+" if Above Top of Casing) T
3 3 1
� � 3 JI
d, TOP OF CASING IS
'Top of casing terminated
a variance In accordance
e, YIELD (gpm) N1a.
• FT Above Land Surface'
f DISINFECTION: Type
g. WATER ZONES (depth)
From To
From To
aVor below land surface may require
with 15A NCAC 2C 0118
METHOD OF TEST
�f Q� Amount
From To
6. CASING:
From
From
From
D
c' To
epthotie
Ft
To Ft
To Ft
From To
From To
From To
Thickness/
Di , +Ier Weigh../
7, GROUT. Depth /� Material Method
From 0 To 7 Ft
From To Ft,
From
8. SCREEN:
From
From
To Ft
Depth Diameter Slot Size Matenal
To 7 Ft .f in in {' G
To \ Ft in in
From To Ft in in
9. SAND/GRAVEL PACK:
Dept Size Material
From r To T Ft ° AI ,7ifid'
From To
From To
10. DRILLING LOG
From To
11. REMARKS:
Ft
Ft
Formation Description
ILL:
/L-
1 \ P
t'r; 0 9 20-10
F''ior,..sUna
h.fnrmatl(�t'' SEng
DW Q/BOt,
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WIN
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECQRD HAS IDED TO TH( WELL OWNER
IGNATURE OFZE}2TTFIEDXtdELL CONTRACTOR DATE
PRI TED NAM 4ee
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