380844_Well Construction - GW1_20100202

1. WELL NTRACT R:
( rEs
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
701
WELL CONTRACTOR CERTIFICATION #
11
WO Contractor (Indmdaal idame
flcr ii t1Il ¶ J )1P1 jrk-
Well Contractor Company Name
,4070 5k4r:Se Qei ve
tr t Address
gnnQpOli5
City or Town
( 7oy) 933-0'179
State
Z0L3
Zip Code
Area code Phone number
2. WELL INFORMATION: //�� �j �J Q
WELL CONSTRUCTION PERMIT# / V O4 l 3 u 5
OTHER ASSOCIATED PERMIT#(f applicable) n/9
SITE WELL ID #(rf applicable) fl I Q
3. WELL USE (Check One Box) Monitonng 0 Municipal/Public ❑
Industrial/Commercial 0 Agncultural ❑ Recovery 0 Injection 0
Imgation'Other 0 (Iis3use)
DATE DRILLED / / ! 7 f 09
4. LL LOCA ON: ,^ ,1
TTripn orive rvisiQn 28 (0?
(Street Na a NNumbe io Ckxnmunrty, Subdmsn, Lot No , Parcel, Zip Code)
CITY (if AT I ,T+k
COUNTY i / leckknb
TOP RAPHIC / LAND SETTING (check appropnate box)
lope [Walley ❑Flat ❑Ridge ❑Other
LATITUDE ", /0 if " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 47 " DMS OR 7X.X00(XXXXX DD
Latitude/longitude source- [+dPS ['Topographic 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.)
n►l niq
Faal Name Facility ID# (rf applicable)
5 i iJelam'.er? Lane
Str
Town
rQt t`Yl i
• e. YIELD (gpm)
- f. DISINFECTION: Type,
g. WATER ZONES (depth)
Top ,.,[,Bottom 3/ (o Top Bottom
Top 4/30 Bottom ("3 / Top Bottom
Top Bottom Top
FT. Above Land Surface'
`Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
d 0 METHOD OF TEST Air it'ssure
rAmount
Bottom
Thickness/
7. CASING: Depth Diameter Weight
Top Bottom )(J Ft (0 t/ 3 `.�rl 80
• Top Bottom FL
Top Bottom Ft
:8 GROUT Depth
• Top 0 Bottom 2-4 Ft
Top Bottom Ft
. Top Bottom Ft.
Material
port
/1 Matenal Method
( efl' f'l+ �ravi +4/
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft in in
Top Bottom Ft. in in
' Top Bottom Ft in in
10. SAND/GRAVEL PACK:
Depth Size Material
• Top Bottom
: Top Bottom
. Top Bottom
= d. TOP OF CASING IS
1
3 ( /.4
pf-i n-e
Ft.
Ft
Ft
11 DRILLING LOG
Top Bottom Formation Descnption
a5 Ra Cla
. as / /3s (Zket / 6 II 1-if
0/
/
State Zip Code /
Contact Na/
'5 5 fam m-
p ela ere L-C 1'1'-e / WATER QUALI I Y 5�� Y�; lot
M m, I'- L�LTf / Inform�ilori ri�.�� ,,,y
/
r.% i—..r"`
G \c.1/ L)
Fk13022010
City or Town State Zip Code
(qD) 355-04/03
Area code Phone number
6. WELL DETAILS: f
a. TOTAL DEPTH: •
5 /
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO le-
c. WATER LEVEL Below Top of Casing �J D
(Use'+" if Above Top of Casing)
FT
/
12. REMARKS:
- 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONST • UCTION STANDARDS, AND THAT A COPY OF THIS
RECORD FPS EEN ENV? WNER
it
SIGNI TTURE OF CERTIFIED WELL CONTRACTOR DA
rl ri 5 MOr' ah
PRINTED NAME OF PER§N 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