397186_Well Construction - GW1_20110919

39?1 6
WELL CONSTRUCTION RECORD
North C:truti)r.t - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
A /V IV y `l�U j7 / Y 14 T CERTIFICATION It to2 J
!\'!•:t.t.('O�"r12.1C"rORt1lpICltZ(t:\L) NAME (print)PHCIICE # {) U�f�ydyo
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S'1'.\►'F: \!'ELi. CONS-I-RU(-I-II)N PERMIT2 _ cif r IicablC}
tifa,tom
wt-:l ] (()\ 1')t\('rOti CO?iPAN!' N. 3IE
:\SSOCt.\'TE1) WQ PERMIT;{
1
Applicable Check Box): Residential Efr Municipal Public 0 Industrial 0 Aaricultural
-
l\'I Lt. t Sl: tC1«
Monitoring 0 Recovery 0 meat rump Water Injection ❑ Oilier If Other, List. Use
2. WELL LOCATION:
Neares Ttneytt:
tSircct Name. Num
3. OWNER:
Address
t r'tr tit 4.r lt.,utr Ni..t 2. 5/ U 3
:k
t'a...r l'trn State Lip Co
Mune number
4. DATE DRILLED 7— 9-a
5. TOTAL
t, DOES WELL REPLACE EXISTING WELL? YES E7 NO ®"
County tom'\
s. i•t111tinunily. Subdi%isn't). Lot No.. Litt C.akl
. STATIC WATER LEVEL Below Top ofse if
FT.
Loptt Casing)
S. TOP OF CASING IS —_ FT. Above Land Surface*
'Top of casing terminated at/or haute land surface requires'a
variance in accordance with I: A NCAC 2C .01 i
9. YIELD ilipm): ---METHOD OF TEST Q =
IO. WATER ZONES tdepd)t:
•
I I. DISINIFC 1
12. C:\SING:
From
FromFrom
13. GROUT:
Front b
From
14. SCREEN:
From _
From
15. SAND}/GRAVE PACK:
Depth
From To
From — _ ___3 o—
16. REMARKS: ys
DO I IEIZEBY t•ERTIFY THAT THIS WELL WAS CONS'TIWC TED IN ACCORDANCE
BEEN WITH
IT I5 TO THE WELL
Topottra hic/Land setting
❑Ridge tE!`Stope °Valley ❑Flat
tcheck appr'priatc host
Latitude: lougittuie of well location
tde`rc .ntinuli so:untici
1_atitude:I1oneitude sourt:e:OGPSOTopouraphic trap
whorl bust
DEPTH DRiLI-lNt� LOCI
From Tu
Fo ,Iat l)n -script ion
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Inclinit: the mad
numbers and common road names.
ON: Typed nP Amount
Wall Thickness
Depth Diameter or Weighti Ft_ Material
To !_ q I't- —�-
To Ft.
To
Depth Material
l.tt Ft
To Ft
Depth
To
To
Ft.
Diameter
Ft_ in.
Ft. in.
FL
Ft_
Method
Slat Size blaterial
in.
in.
Size Material
h
ECEIVED
UGj9 Z011
anon pro
DwQ/@pGsin9 Unit
OWNER
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD_ 1
�..
SiGNA RE OF PERSON CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality. Grnundi ates Section, 1636 Mail Service Center- Rate gh. NC
4 r71.0.110 tilt. (9191733-32? 1, within 30 days.
DATE