390562_Well Construction - GW1_20110107

ity or Town
Area code Pho e number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 36
(Use "+" if Above Top of Casing)
5/60
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of'Water Quality _
WELL CONTRACTOR CERTIFICATION # 3 6 3 c
1. WETRACTOR:
11(
ilk/ Contra (Individual) Name -
(f ui l,S cam(L 7i((ilaf3
/Mad m a • Nam
mph, �9 141
1 Rd
St et Address
o Iv c� 3aa 7
or Town State Zip Code
(2114) `-` <) S 6(c, 9'/
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# /6 " / 9 V
OTHER ASSOCIATED PERMIT#(inapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑
Industrial/Commercial 0 Agricultural VRecovery 0 Injection 0
Irrigation Other 0 (list use)
DATE DRILLED /6 -Ida- /O
4. WELL LOCATIO
(Street Name, Numbers, Community, Subdiv ion, Lot No., Parcel, Zip Code)
CITY: COUNTY (.J_n
TOPOGRAPHIC / LAND S G: (check appropriate box)
O Slope ❑ Valley 0 Flat Ridge 0 Other
LATITUDE 36 " DMS OR 3X.XXXXXXXxX DD
LONGITUDE 75 " DMS OR 7X.xX)0xxxxxx DD
Latitude/longitude source: S OTopographic 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.)
Facility) Name
Street Address
Facility ID# (if applicable)
City or Town State Zip Code
L.- rvbrTh
(\ ?�'1
M 'ling Address
Or1v0� )?tlO
State Zip Code
NO
FT.
uJe(a
d. TOP OF CASING IS I 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): /0 6 71- METHOD OF TEST /9 / !_x
f. DISINFECTION: Type 1/217/71
g. WATER ZONES (depth):
Top / 6, 6 Bottom / 6 S7
Top
Top
Top
Amount
/o%vit,%
Top
Bottom
Top Aj (16 Bottom ASO Top Bottom
3a O
Top 3 /5 Bottom Top Bottom
7. CASING: Depth 1 Diameter
O Bottom 5 S Ft. 6 7p
Ft.
Ft.
Bottom
Bottom
Thickness/
- Weight Material
8. GROUT: Depth Material �-- f
Top Bottoittal Ft. �%UT 2r /P ,j%/jwf'°l
Top Bottom Ft
Top Bottom Ft.
9_ SCREEN: Depth
Top Bottom
Top Bottom_
Top Bottom
Diameter Slot Size
Ft. in. in.
Ft. in. in.
Ft. in. in.
Material
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
12. REMARKS:
Formation Description
DWQ/BOG
1 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..
SI
TURE OF CERTIFIED WELL CONTRACTOR
•
0 Z-10
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Form GW-ib