398439_Well Construction - GW1_20110930

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department or F.nvirnnment and Natural Rcanurccs- I Hvision of Wnter tjualit)
WELL CONTRACTOR CERTIFICATION 11 313o2A
1. WELL CONTRACTOR:
t7rA�KlE L. 01.-rvEYt
Well Contractor (Individual) Name
tU vA Wit D(2tt.x,.+&
Well Contractor Company Name bm/►� %�
STREET ADDRESS lo// trrE�NN I
00,41e( etc
City or Town State
( 7o,1). ter—gorS
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Rif applicable)
STATE WELL PERMIT1(if applicable)
DWQ or OTHER PERMIT N(0 applicable)._._ 1/11/
WELL USE (Check Applicable Sox) Monitoring n MunicipaUPublic f 1
IndustrlaUCommerclal p Agricultural n Recovery 0 Infection f1
IrrIvellon(9 Other. O (list use
DATE DRILLED 57/0I/
1/400 AM p PM EY
2/2
TIME COMPLETED
Zip Code
3. WELL LOCATION:
CITY: t.JRXsiAra COUNTY UA+ror
mar . e EPA 10
(Street Name. Numbers. Community. Subdivision. Lot No.. Parcel. Zip Code)
TOPOGRAPHIC 1 LAND SETTING.
°Slope DVeley 3#Iat °Ridge 0 Other
(cock approprlsts box)
LATITUDE • S ° 02.ggz -
LONGITUDE 09 f$.9220
Latitude/longitude source: dGPS °Topographic map
(bcatbn olllel must be shown on a USGS topo map end
inched to thb form If not using GPs)
4. FACIUTY. N M naae of h business where the well It teeeted.
FACILITY ID t(i( applicable)
NAME OF FACILITY
May be in decrees.
minutes. seconds or
in a decimal format
STREET ADDRESS
City or Town AState Zip Code
CONTACT PERSON %`riq/�q} .y- T ,-r1s,.a ic? Any✓
MAILING ADDRESS 52o (,r%k/".E '7 iciavece
4.1eAxN,Aka Ne- 2$I73
City or Town State Zip Code
( 704 ). 2310 - 7193
Area code • Phone number
5. WELL DETAILS:
•. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Cie
c. WATER LEVEL Se(W Top of Casing: 10 FT.
(Use'•' if Above Top 01 Casing)
d. TOP OF CASING IS / FT. Above Lend Surface'
•Top 01 casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .011a.
e. YIELD (gpm) „Q1' D METHOD OF TEST Aa-
r. DISINFECTION: Type 7o'4 t#n Amount 34, oz
g WATER ZONES (depth)
From %2 To 7? From (1210 To i/(5'/
From 78 - To 79 ✓ From To
Fromyy(_ To 4//4 ' From To
O. CASINO: Tliicknees,
Depth Diameter Weight Material
From (9 To (' & Ft 4 '4" &OR 21 Piet_
From_ .._ _. To.-- Ft
Froni To Ft
7. GROUT: Depth Material Method
From_ D To 2p+ Ft &mob./?Tin
From To FI.
From To Ft
S. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Depth
From
From
From
PcAriP
Diameter Slot Size MeteAe1
Ft. In.
Ft in.
Ft. In.
To Ft.
To Ft.
To Ft.
10. DRILLING LOG
From To
fs''" /5
/3' sr
6Co
11, REMARKS:
In.
In.
In.
Size Material
Formation Description
aiow�
e—A-zle AN t tea('
Rfa..✓A y: /moo_ K
r f'r
SEP 3 0 2011
" T Ulltl
rnvurl-atlU(i f'fUC@SSWIi,�
100 HEREBY CER TW Y THAT THt3 WELL WAS CONSTRUCTION ACCORDANCE WOW
ISA NCAC 2C. WELL COHSTRVCTION STANDARDS. AND THAT A COPY Or THUS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF RT� WELL CONTRACTOR
5-17-11
PATE
j9 wse L . °ova z- 3). Mcl//•✓atrY
PRINTED NAME OF PERSON ONSTRUCTINQ THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center — Raleigh, NC 27699.1617 Phone No. [phone] ext 566,
Form GW.1b
Rev.1/05