WQ0005849_MW-8_20200831

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.NONRESIDENTIAL WELL CONSTRUCTION RECORD
(mo t North Carolina Department of Iinvironment and Natural Resourcest/- Di'v�''' ion olf`t�Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CMC
Well Co tra or Individual) NarnP
Well Coma®r Compa Name AC
St r t Add es ��
City or Town State Zip Code
Q51- 666q__
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERM
OTHER ASSOCIATED PERMIT#(if applicable)______
SITE WELL ID #(if applicable) _
3. WELL USE (Check One Box) Monitoring Municipal/Public
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection rl
Irrigation❑ Other [. (list use
DATE DRILLED- J _
4. WELL LOCATION:
--------- ----- -----
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: __ /1--� 1 COUNTY.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
(-]Slope [-]Valley []Flat ❑Ridge []Other.
LATITUDE 36 _" DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75_._ °u' " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS Q[opographic 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.)
ac'S L.LC-
Facility N 7 q �, H coV �Ftceilijty ID# (if applicable)
StreetAddress;act �4 j y
City oTOw.�n � � ,5 � State Zip Code
Contract i
Mailing Address
5nEP,C) ��'/ N � q
City or Town State Zip Code
(qto)~ a��a
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO j}-'
c. WATER LEVEL Below Top of Casing: lJ FT.
(Use "+" if Above Top of Casing)
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): T5__— METHOD OF TEST >,� -
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top_'-�,Q,0 Boltcmz:O Top__
_ Bottom____ —
: Top_ Bottom_.___ Top
___Bottom
Top__ Bottom__
Thickness/
7. CASING: Depth Diameter
eight i�a;�ial
Tope Bottom 0_. Ft. Q
��
1Lt [��'� }`Joe_
--------.11
Top Bottom_ - Ft.__
Top_—__ Bottom Fi.
8. GROUT: Depth Material Method Q
Top _ Bottom Fi.�
Top _ Bottom`___ Ft.__
_
Top Bottom Ft.
9. SCREEN: Depth Dia eter
Tope
Slot Size Material
Bottom-- Ft. in.
_l in. _-u l _
Top--_-_ Bottom __ Ft. _in.
in.
Top Bottom Ft. in.
in.
10. SAND/GRAVEL PACK:
Top—�0Depth Sirz�j Material �+ t
—Bottom ✓�_ Ft._ �\ Qt/Zt
Top BottomFt,
Top Bottom^_____ Ft.
11. DRILLING LOG
Top Bottom
12. REMARKS:
Formation Description
Ut .
_CAW 0.
5 C --
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2CPOFCERTIF111
TRUCTION STANDARDS, AND THAT A COPY OF_TH�G•--
RECORD HASDEO 7 'I'fE WELL NER.
SIGNATUR WELCONTR CTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Form GW-1b
Y P ty - Information Processing, Rev. 2l09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]