383839_Well Construction - GW1_20100428

WELL CONSTRUCTION RECORD
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North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
\VELLCONTRACTOR (INDIVIDUAL)NAME (print) .2 3ehQ. p 6 CERTIFICAITIION# ../ lt//
\VELL CONTRACTOR COMPANY NAME t(G2-1Ge- /Jed/ Dr- I) : 14Sa PHONE #�d 7) ir3 Y'0 67
STATE \\'ELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# K.P11 d tI. &A -say / 6 "Zi0
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential,—iunicipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery ❑ Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATIO :
Nearest Town: 64 ✓n-e-- Countyah t ®n
76 Zd 1�,.,�s/e-f f/w„.'•
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:AC1.4-e_, � ST�✓vice
Address %6Z06 L Ca -shed'
(Street or Route No.) a.k�a W C_
Z,5/73
City or Town State Zip Code
&) Z-Z/ -6//Z. •
Area code- Phone number
4. DATE DRILLED S' -/- / 15
5. TOTAL DEPTH:.�ps
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO A=1"----
7. STATIC WATER LEVEL Below Top of Casing: 2 G FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gpni): Z METHOD OF TEST /9V ✓
10. WATER ZONES (depth): Fq
11. DISINFECTION: Type /I--%I�% Amount / 6 0 Zr
12. CASING:
Wall Thickness
Depth 1��% Fi meter or Weight/Ft. Material
From — / To 7 t. ,%- OZ-2-/ /7VVG
From To Ft.
From To Ft.
13. GROUT: Depth Material �ff Method
From 0 To 3 S Ft. �'��` 4:-. tTe., pi..... e
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
Topographic/Land setting
❑Ridge Brst6pe ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To e4 ,Formation pe$cription
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
' oS
E EIVED
MAY 2 8 2010
Information Processing Unit
16. REMARKS: DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
0 SIGNATURE OF PERSON CONSTRUCTING THE WELL
DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. . GW-1 REV. 07/2001