382327_Well Construction - GW1_20100409

Area code- Phone number
2 WELL INFORMATION
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division or Water Quality
WELL CONTRACTOR CERTIFICATION # dg5p
1 WELL CONTRACT
;th
Well Contractor (Individual) N
Well Well Contractor Company Name
STREET ADDRESS °KM MAI;eid,t:
City or Town State Zip Code
( )- ELK - a.t go L s/4-
SITE WELL ID #(if applicable) 161:). 771/
77
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring* Municipal/Public 0
IndustriaUCommerclal 0 Agricultural 0 Recovery 0 Infection 0
irrigation❑ Other 0 (list use)
DATE DRILLED goo ,(
TIME COMPLETED cJ ov AM (glePM (t'
3 WELL LOCATION'
CITY/ t.�r4_/tJQ�Ol4 COUNTY
it /t ire
t lL-�
(Street Name Numbers, Community, Subdlesion, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ®Flat ❑Ridge 0 Other
(check appropnate box)
LATITUDE j_
LONGITUDE
3-//—/O
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source ■GPS ❑Topographic 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 Gy/� STREET ADDRESS //! D /D
City or Town
CONTACT PERSON
LstatE.'
of r69
City or Town State
( 70 -) 5fG do
Area code • Phone number
5 WELL DETAILS
a TOTAL DEPTH s_ $
b DOES WELL REPLACE EXISTING WELL? YES 0 NO 1!
c WATER LEVEL Below Top of Casing J
(Use "+" if Above Top of Casing)
FT,
e
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) fill. METHOD OF TEST
f, DISINFECTION. Type kl/I_. Amount
g WATER ZONES (depth)
From To From To
From To From To
From To From To
6. CASING j�
0
DTof 1J t Dia ter 5 WWrh4d ,7C_
From
From To Ft
From To Ft
7. GROUT
Depth 1 Material
;
Thickness/
From 0
From To
From
8 SCREEN:
Ft
To Ft
Depth Diameter
From To jg 7Ft of n
From To \ Ft in
From To Ft
Method
Slot Size
/0 in
in
in in
9. SAND/GRAVEL PACK:
RYD�l From To ► Ft �- Fl
Material
Material
From To Ft
From To Ft
10 DRILLING LOG
From To
Formation Description
�r, 5 c�j �--
11. REMARKS.
A ro
9 l �
G!rt (, 9 71110
_'SSSriJ Unit
DWQ/P.OG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wrni
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS $F66L YIDED TO THL WELL OWNER
IGNATURE OF
ELL CONTRACTOR DATE
PRI I ED NAM OF 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 tb
Rev 7/05