407280_Well Construction - GW1_20120827

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1. WELL CONTRACTOR:
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NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality!
WELL CONTRACTOR CERTIFICATION #
W Contractor, (Individual) Name
Act r, t i
':/Well Contractor Company Name
/j
STREET ADDRESS //// Pt) =/ P�c-�` 4-0,5
Zip Code
f-07
City or Town State
9V7
Area code- Phone number
2.
WELL INFORMATION:
SITE WELL ID #(if applicable) 252
STATE WELL PERMIT#(If applicable}
DWQ or OTHER PERMIT #(if applicable)
WELL. USE (Check Applicable Box Monitoring 0 Municipal/Public 0
Industrial/Commercial gricultural 0 Recovery 0 Injection 0
IrrigationD Other 0 (list use)
DATE DRILLED
TIME COMPLETED �✓ 0
3. WELL 710N:
CITY: rCOUNTY
CA-,} 9'
treet N rne, Numbers, Community, Subdivision, Lot
TOPOGRAPHIC / LAND SE . ING:
0 Slope QValley t °Ridge 0 Other
(check appropriate box)
LATITUDE 3 .�
LONGITUDE ,,/p//
Latitude/longitude source: G Topographic map
(location of well must be shown on a USGS top map and
aftached to this form if not using GPS)
4. FACILITY -is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY .j'M j- 0 it /1K
AM 0 PM Q--
No., Parcel, Zip Code)
May be in degrees,
minutes, seconds or
in a decimal format
STREET ADDRESS / �r�
t �'( 't ei
,j f' " • S
City or Town - e ip ode
CONTACT PERSON To. )JA/ ti)ACV7
MAILING ADDRESS
9Y3
C�s City or Town State
3-3
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: C
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: FT.
(Use u+" if Above Top of Casing)
C '• ,o
3 •fin. s
d. TOP OF CASING IS -- FT. Above Land Surface*
*Top of casing terming at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): ::....?0() METHOD OF TEST
f. DISINFECTION: Type /4 u .dAmoun ce,‹* Ai'
g. WATER ZONES (depth):
Fron 260 To se,`) From To
From To From To
Frorn To From To
6. CASING: Thickness/
Depth Diameter Wei ht Material
From c) To Ft. 7 /'r '
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From T , Ft.
From To Ft.
From To Ft.
8, SCREEN: Depth Diameter Slot Size Material
In. ��7 .AMR • tp_eZ,w Fr ToJFt.
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth;
From ie,fl Ft.
From To Ft,
From To Ft.
S' a Material
10. DRILLING LOG
From To
3P--
nng
do=
Agr.4(
f -h2$C1
40-7.
PRl
S
Formation Description
e
34/ .ft-"< Cr 1, n-
Ih.:�•n9 F�qg
AUG 1 0 2012
THIS WELL WAS CONST CTED 1M A.CCORDANCE WITH
TMON AN' = ' = ' , Na THAT A COPY OF THIS
D TO w - ' LL OWNER.
IFIED WELL CONTRACTOR
Pa 1
DATE
ED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-lb
Rev. 7/05