380483_Well Construction - GW1_20100122

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a .2 / 3 A
1 W C/A (LfL-OR. I G �/1 p l (% J
WAIISCon cctor (8d,,dual) NameY �N /i
Well Contractor Compane
PO any 398
Street Address
City or Town
(?m/) )32 -33c l
Area code Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring.(Municipal/Public ❑
Industnal/Commercial ❑ Agricultural ❑ Recovery 0 Injection 0
ImgationD Other ❑ (list use)
DATE DRILLED / " /49 —% 0
AL C-4
State
7808'0
Zip Code
4. WELL LOCATION•
3(y 5. -TryOti S1L
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Tip Code)
CITY r lb fie COUNTY inPc.(th„,a t!�
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑Valleyt ❑ Ridge ❑ Other
LATITUDE 36
" DMS OR 3x.xxxxxxxxx DD
LONGITUDE 75 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source [SPS Qfopographic 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 ) /
Facilty Name Facility ID# (if applicable)( 30
i�©ti s�
Str et Addrgsse
3 0483
d. TOP OF CASING IS _ FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
Top 0 Bottom (S. Ft 0
Top Bottom Ft
Top Bottom Ft
Thickness/
Weight Material
Sc%i t/d 0/O
8 GROUT Depth Matenal
Top 0 Bottom I( Ft. C' Ann er-)
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth Diameter
Top (S Bottom 20 Ft 0 in
Top Bottom Ft in
Top Bottom Ft in
10. SAND/GRAVEL PACK:
Depth Size
Top 13 Bottom 30 Ft tt a
City or Town State Zip Code
eL.e,,s -(hies;;z4a j u _s
Contact Name
Mailing Address
City or Town State Zip Code
(76y) /6 — 0") Co /
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: ? 0
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO,E(
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /
/
/
/
/
/
/
12. REMARKS:
4.pD11
Method
r7nvRe1Q
Slot Size Material
, 016 in PUC-
in
in
Material
We_Q. Q SrM �Q
Formation Descnption
SO', 1
1-?I—IfE 'TO
-
•IQM 2 2 2010
tfvt - ION
Inrorm <Ion Processiri4 Unit
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC
ELL ONSTRUCTION &6VI EDJ3-HWNERE�A(ELL STANDARDS, AND THAT A COPY OF THIS
RECORDBEEN P0
SIcNA RE •F ' ERtifFIED WELL
ONTRACTOR DATE
c. WATER LEVEL Below Top of Casing FT ��i VIZ OF C� (
(Use "+" if Above Top of Casing) PRINTED NAME 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