382335_Well Construction - GW1_20100409

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION # 5t
1 WELL CONTRACT
1111 �RJeLede.i
Well Contractor (Individual)e
Well Contractor Company Name
ADDRfikiESS 1oRs \f (e1t' r�,
,sSTREET
,c-taL_______autz___
City or own State
(_R():)- ELK- a18O
Zip Code
4_3''} X/
1
! ✓ 7 7 .oie/
Area code- Phone number
2 WELL INFORMATION, b
SITE WELL ID #(il applicable) So�!
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring * MunicipaVPublic 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
IrngationD Other 0 (list use)
DATE DRILLED 3 —//0 — 40
D PM L '
,(/ec-.�Q.
/�a
�[ TIME COMPLETED ZOO AM
3 WELL LOCATION:
CITY/ S�/+•�G/CJLX�Qvic.cj'-
QCOUNTY
/{1/t /tQ 111—
(Street Name Numbers Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
°Slope °Valley ®Flat ❑Ridge 0 Other
(check appropriate box)
LATITUDE
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source ■GPS °Topographic map
(location of well must be shown on a USGS topo map and
attached to this tom, if not using GPS)
4 FACILITY is the name of the business where the well Is located
FACILITY ID #(if applicable)
NAME OF FACILITY/ � � _,�L.ei�fs
STREET A DRESS , �D
//
City or Town State I od
%9i%A CONTACT PERSON 72
M A D ESS
:CAA.
City or Town State
( 7e4 )- SPA avO7
ip Code
YES 0 NO
FT
Area code - Phone number
5 WELL DETAILS qi
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing
(Use '+" if Above Top of Casing)
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
e. YIELD (gpm) NA. METHOD OF TEST
Amount
f. DISINFECTION Type kl/Qr
g WATER ZONES (depth)
From To From To
From To From To
From To From To
6. CASING: Thickness/
From D DTo(h�y
J Ft ter noghr�J�ey�
From To Ft V J� 0 r Y!/ -
From To Ft
7. GROUT' Depth? y Material /� Method
From 0 To j Ft � ' r7 4//`
From To Ft
From To Ft
8. SCREEN: Depth �J Diameter Slot Size /M/atenal
From 5, To �J Ft Min �O in �!�
From To \ Ft in in
From To Ft in in
9. SAND/GRAVEL PACK:
Depth Size Material
From eYi To V. Ft c:,f , 5', .UC/
From To Ft
From To Ft
10. DRILLING LOG
From To Formation Description
11 REMARKS•
a
IP1e ., G— PC re""
Y
/-i-I•t a 20
Information 1-,c‘cz.sstng unit
UVV� UbUi.7
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WrrH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REC,QRD HAS __.! IDED To TH( WELL OWNER
IGNATURE OF
YetPRIAM OF
,3- /D Zv
FIEDIMELL 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 lb
Rev 7/05