406577_Well Construction - GW1_20120820

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1. WELL CONTRACTOR:
GA a()
Well Contra r (individual) Name
u� e�
Contractor Company Name
Street Address
, _d_Int?05)
iloo•
City or Town
( 146 ) 5 '3-- f
Area Dods Phone number
2- WELL INFORMATION:
WELL CONSTRUCTION PERMIT! P�
OTHER ASSOCIATED PERMIT#(q applicable)
817E WELL IO N'dApplioade►
State Zip Code
3, WELL USE (Check One Box) Monitoring 0 MunlcipaUPublic 0
Industrial Commercial 0 Agricultural 0 Recovery 0 Injection O
Irrigatlok Other 0 (IIs1 use)
DATE DRILLED .? 5 —' 2'
4. WELL LOCATION:
e
Community, Subdivision, t+lo. Pence
(Street Neniei, Nurnberg, ityf 1, 21p Code)
ioe , coUNTY 0/cx.L
TOPOGRAPHIC I LAND SETTING: (check eppropnate box)
°Slope O Valley O Ftat O Ridge 0 Other
LATITUDE 3. , DMS OR 3x.xxxxxXxxx OD
LONGITUDE °,j 4 " DMS OR DO
Latitude/longitude source: PS °Topographic map
(location of wall must be own on a (/SGS topo map andattached to
this form if not using GPS)
B. FACILITY (Name of the business where the well is located.)
F®CIIib Name
Facility IDS (If applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
e. WELL DETAILS:
a. TOTAL DEPTH:
ate'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
C. WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
NONBESIDEI!TJAL WELL CONSTRIJCTJON RECORD
North Carolina Department of Environment and Natural Reoouros. Division' 0 of Water Quality
WELL CONTRACTOR CERTIFICATION #
d. TOP OF CASING IS FT, Above Land Surface'
'lop of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118,
e. YIELD (gpm): METHOD OF TEST tclpfl
f. DISINFECTION: TYPe Amount
g. WATER ZONES (depth):
Top 6otton!
TopBottom
: Top Bottom
7" CASING: Depth
Top f Bottom,,2o
Topes Bottom
Topes______ Bottom
8. GROUT: Depth
Top in Bottom O
Top_ Bottom
Top-- Bottom
9. SCREEN: Depth
Top gAtJ Bottom
Top Bottom_
Top e
Olemt�t
Ftf
fil•
•ms : t•
Top Bottom
Top Bottom
Top Bottom
Thickness/
MMe1pM Material
$:ij
�, Ft•
— Ft.
FL
Material
Ft. /Affe2._. eikci
Ft.
Dlamstor
Ft.•, ' In.
Ft.= n.
Ft. tn.
Shot Size
e/0
Method
/41.&"°'
in.
in.
in.
Material
/4)()C°
:10. SAND/GRAVEL PACK:
Dept Sias Material
Top Bottom_,__ Ft.
Top Bottom Ft,
Top Bottom Ft,
: 11. DRILLING LOG
Top Bottom
, "
I _
"
12. REMARKS:
Formation Description
/!I
'Call; ^'
.•E_.. yE sT F —
e.
100 HEREBY CERTIFY THAT THIS INEII WAS CONSTRUCTED IN ACCORDANCE WITH
- 15A NCAC ZC, WELL CONSTRUCTION STANDARDS, ANO THAT A COPY OF THIS
: Aa40RD HAS % EEN PROVIDED TE EU. OWNER.
SIGNAT
E OF RTIFIE ' LL
= PRINTED NAME
CONTRACT-6R DAB
F PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Malt Service Center, Raleigh, NC 27699.161, Phone : (919) 807•6300
RECEIVED 07-11-'12 07:36 FROM- 9103133102 TO- NC DENR P&S
Form GW l b
Rev. 2/09
P005/007