WQ0005849_MW-9 & MW-10_20201008

I�
NTIAL WELL (
JCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # T// 9
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable) �CA, ` eH i• n
3. WELL USE (Check One Box) Monitoring "unicipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list u$e
DATE DRILLED 1 n
t��reet Name, Numbers, Co munity, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY O O
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valleyy DFlat If
❑Other
LATITUDE 361V `� `\�" DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 a " DIMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: [)6PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY Game of the business where the well is located.)
Facility
Area code Phone number
racuny lurr (ir appncaoie)
d. TOP OF CASING IS FT. Above and Surface`
'Top of casing terminated allor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST .
f. DISINFECTION: Type_ Amount
To WA NES (dept `
p � Bottom �' Top
Top_ Bottom Top
Top Bottom Top
7. CASING• Depth ll��//ff�� f Dia eter
Tope Boltom"oti� FL
Top Bottom Ft.
Top Bottom Ft,
8. GROUT: Depth r �
Top _ Bottomn-
Top Bottom
Top Bottom
Bottom
Bottom
Bottom
Thickness/
Weight ate0al
Sch � vc.
Material � Method
Ft. e ti l�
9. SCREEf�; Depth � Diamf�er
Top Boltom7 Ft.in.
Top Bottom Ft. in.
Top Bottom Ft. in.
Slot Size ate ial
in.
in.
10. SAND/GRAVEL PACK:
Top`—Botttom`� `Ft.-V1<;oL C11
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
Ae
i
ti
72. REMARKS:
6. WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTR
NCAC 2C, WELL CONSTRUCTION STANDA DS AN
a. TOTAL DEPTH: REcolzo S B N VIDE TO THE OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
: SIGN TU OF CERTIFIED WELL CONTRi
c. WATER LEVEL Below Top of Casing: _ FT.���hr1
(Use "+" if Above Top of Casing) PRINTED NAME OF PERSON CONSTRUCT
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
CTED IN ACCORDANCE WITH
THAT A COPY OF// THIS �(�\f
�yV-V
3TOR DATE
G E WELL
Form GW-1b
Rev. 2/09

1. WELL CON
number
2. WELL INFORMATION:
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Waler Quality
WELL CONTRACTOR CERTIFICATION # ` L 'A
d. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
( e a variance in accordance with 15A NCAC 2C .011 I�I�t{� ' e YIELD (gpm):, METHOD OF TEST lc ,
y Name \` 4
t�i\ ��1'ifl :f. DISINFECTION: Type Amount
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable)
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED
4. WELL.LOLATION:
bl No., Parcel, Zip Code)
CITY: J \ lclai%t'J 1 G� COUNTY bW
TOPOGRAPHIC /LAND SETTIeck appropriate box)
❑Slope ❑Valley Z;F k—QRidge ❑Other
LATITUDE 36 No P " DMS OR 3X.XXXXXXXXX DD
LONGITUDE ?T IL" DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS pTopographic 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.)
Name, Numbers,
Faci
City or town
Mailing Asld�re/sPs��
City or Town
Area code Phone number
6. WELL DETAILS: �
a. TOTAL DEPTH:
ID# (if applicable)
�.c
State
Zip Code
g. WATER ZONES (depth
Top_
10
Bottom .• Top Bottom
Top_ Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight M�a rial
Top ,_. Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top Bottom Ft.OU is . J
Top Bottom Ft,
Top Bottom Ft.
9. SCREE � Depth � Diameter Slot Size
Top•�L_ Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Material
10. SAND/GRAVEL PACK:
Depth � Size Mater' l
ToPBollom FL�� �[� e,,ntt�1,Q
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Noe
/
/
Zip Code
12. REMARKS:
b. DOES WELL REPLACE EXISTING WELL
YES ❑ NO ](�
c. WATEF�LEVEL Below Top of Casing: "' FT.
(Use "+" if Above Top of -Casing)
I DO HEREBY CERTIFY TH��T THIS WELL WAS CONSTRUCTED IN A DANCE WITH
15A NCAC 2C, WELI,COI�r]TRUCT - TANDA$DS, AND TH COPY OF THIS
RECORD HAS BE P ID O THE W Id�6AVER. �
�RE'OFtCERytgf 1D W
PRINTED NAME OF PERSON CONSTR
THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-1b
Rev. 2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]