383443_Well Construction - GW1_20100513

NON ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality so
WELL CONTRACTOR CERTIFICATION # LC)-.7
1 W jL}� CONTR/ TOR [A,A
4� EL,/ E: f ICE I4 el'
l
Well Contractor (Individual) Name
Well Contract C mpanv Name J
L SG, 6. J- spa Ct rr_�.Q e-
St eet Address
C-I0 -C 1.9 i U6 c 35 WO co
City or Town
(g5 ) 85a 0°15
Area code Phone number
2 WELL INFORMATION ^� [7�
WELL CONSTRUCTION PERMIT# W Sit 03 OO S
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) A)/A
SITE WELL ID #(if applicable) OFF W( IN D
3 WELL USE (Check One Box) MonitoringkMunicipal/Public ❑
Industrial/Commercial 0 Agncultural 0 Recovery ❑ Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 4-1— (1 a-` (
4 WELL LOCATION
-3 r o o(d) 5-r i crier -re .0
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY
AJ©b1E
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑ Valley V Flat ❑ Ridge ❑ Other
LATITUDE 41436 ° ' t(( /J " DMS OR
LONGITUDEi78C9 "611 ' (1 i1•1 " DMS OR
Latitude/longitude source PS E ropographic map
(location of well must be show on a USGS topo map andattached to
this form if not using GPS)
5 FACILITY (Name of the business where the well is located )
6 Eo t • Fen. ,u "(.0-•
DD
DD
Facility Name Facility ID# (if a p cable)
old Ct'-el e c ere 1
Sire t Addre s
C.JL, AA 0 t(
City or Town
�-1 / AD c 420.E
Contact Name
3 9.- ((
Ai 028
State Zip Code
Mailing Address
C-4A /t- CO' &'
City or Town
(—zoti) 3(9 - 35
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
5O
/t) c a8a1O
State Zip Code
b DOES WELL REPLACE EXISTING WELL?dd YES IDN(31
c WATER LEVEL Below Top of Casing i► j g le FT
(Use "+" if Above Top of Casing)
v 3 `i `1 c:
d TOP OF CASING IS © 1 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
g WATER ZONES (depth)
Top Ls- (R Bottom
Top Bottom
Top Bottom
7 CASING Depth
Top DZ Bottom "VP(
Ft
Top Bottom Ft
Top Bottom Ft
Amount
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Cch Zf6 tpe G
8 GROUT Depth Matenal Me/Yhod
Top (1 Bottom 46r Ft �u� acid-. 9ftC,t f MT
`Ai•iru rG
Top Li 01 Bottom 3, Ft • cr S
, Top Bottom Ft
9 SCREEN Depth Diameter
' Top —17r Bottom `J01 Ft a(( in
Top
COUNTY et✓r�I�A3' Top
Bottom
Bottom
Ft
Ft
in
in
Slot Size Material
...321-SI, in 9VC_
In
in
10 SAND/GRAVEL PACK-
Depth Size Material
Top Li .3` Bottom SO Ft / SAP(, 0
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
Ft
Ft
Formation Description
o ( 05' � �- ( c (Avcry
ui t / So r le-,0 /(.ce-k-
/ IIn r" 0 e .r F_:
/
/
/
12 REMARKS-
9 N.I_., ., N o^ r
Intormaiiott rscx..��+,iy
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS
• 15A NCA 2C, WELL CONSTRUCTS
RECORD AS BEEN PROVIDED TO
TELL WAS CONSTRUCTED IN ACCORDANCE WITH
N STANDARDS, AND THAT A COPY OF THIS
HE WELL OWNER
SIG A URE OF CERTIFIED WELL C NTRACTOR •,, / DATE
t d //U ' • 1 0( N 12- (C•M
• PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 • days of coinpletion'to:,Division of Water Quality -Information Processing,
1617 Mail‘Service Center, Raleigh, NC 2769'9-161, Phone : [phone]
Form GW-lb
Rev 2/09