389685_Well Construction - GW1_20101201

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NONRESIDENTIAL r ONRESIDENTIAL WELL CONSTRUCTION CORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # -
1. WELL,CONTRACTOR: 7`r
Well Contractor(Individual) Name
S/4r*7-b
Well Contractor Company Name
90 RV A-'c ri-1- Fi et a Or
Street Address
Fo d VA; 11
City or Town
( ) 5 I ,eO
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
c2,9707
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ve-Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED /0 ' S' /
4. WELLELOCATION: 1 n ``
86 �iiC_L�,vc�SGw ►K F.oc\
(Street Name, Numbers, Community, Subdivision, Lot N6., Parcel, Zip Code)
CITY: Nk.) "-*1( ( COUNTY °'1 t0 V
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑ Ridge ❑Other
LATITUDE " DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: ❑GPS Dfopographic 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.)
EF cility Name Facility ID# (if applicable)
6 S uL.r�is0l, - Nt.►6 (Z G
Street Address
I t J CC,)/ cOAJ /() C.-
City
or Town State Zip Code
1 • ' (1,v'0 c- If •+ ,t) S S
Contact Name
bD C) Per'l vv. E' 1--Qr P �.IL- 1 rive -15`4-4Oe
Mailing Address
rnvrrlSv)1e iv.C:- a�15bo
City or Town State Zip Code
(COCA ) 1-161- 1423
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
�I
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO e
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
4 C35.
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): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top (;` Bottom / Ft. Pi/ G
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Material Method
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top /!' Bottom ?.1 Ft. i t in. -0 /0 in. Put-
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom 2 Ft. S cc.vv a
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Formation Description
/ (oZ f!4C Qir±
deck �i�.r ,�-- s ,
/.
/
/
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12. REMARKS:
n 1 2nl0
Information Prrc:-
DW /sr _th
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 HABEEN PROVIDE D QO THE NIELL OWNER.
SIGNATU E OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mali Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09