406576_Well Construction - GW1_20120820

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HUura
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Ity or Town
Addross
en Contractor Company Name
4.7 Addre6s
( 91d)�4S -i 4 B�
Area code Phone number
2.WELL IN FORMATION :
WELL CONSTRUCTION PERMITS stii0
OTHER ASSOCIATED PERMIT#(it applicable)
SITE WEU. ID fig applicable)
1. WELL CONTRACTOR:
NONRESJDENTJAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources. Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
d. TOP OF CASING IS e4 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 (pm); v METHOD OF TEST frit I
t. DISINFECTION: 'type Amount
g. WATER ZONES (depth):
Top Bottom Top, . Bottom
Top Bottom TopBottom
Top Bottom., „ Top Bottom
Thkknetsl
: 7. CASING: Depth Diameter Weight Material
Top .. ' 8ottomA Ft .2.
Topbottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top d Bottomw . Ft,
: Top Bottom
Top BottomFt.
Wel Contra ¢or(Indhridual) Name
RC
dAn- gie,eds
Slate Zip Code
9. WELL USE (Check One Box) Monitoring 0 Municipal/Public Q
Industrial!Commerclal O Agricultural 0 Recovery 0 Injection 0
Inigationtit Other ObEist use)
DATE DRILLED ' Al--
4. WEU. LOCATION:
(Street Name, Num ,
CITY:
Conanunlgl, Subdivision, Lot No., Paul, Zip Code)
COUNTY ,:
TOPOGRAPHIC i LAND SETTING: (check appropriate boa)
C1 Slope p Valle Oat Q Ridge O Other
LATITUDE , ' Z- "DMS OR 3x.Xxxxxxxxx Dp
LONG ITUDE3d)1°, ' 5'? ° DMS OR TX,XX X 00
Latitude/longitude source:eps
DTopographlc map
(location of well must be a on a USGS topo mop andattached to
this fo m if not using GPS)
6_ FACILITY (Name of the business where the well Is located.)
Facility Name/041
Street Address
Facility IDd (if applicable)
City or Town
State Zip Code
Contact Narne
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: Off
b. DOES WELL REPLACE EXISTING WELL? YES 0
N�
c. WATER LEVEL Below Top of Casing; � FT.
(Use '+' If Above Top of Casing)
Material
Method
0401e a,�r
9. SCREEN: Depth Diameter Slot Size Materiel
Top, in , Bottom 0 Pt./ toOf in.
TopBottom Ft._ in.
Top Bottom Ft. In.
10. SAND/GRAVEL PACK:
Depth
010
in.
in.
in.
Size *torte'
Top Bottom Ft.
Top BottomFt.
Top Bottom Ft,
11. DRILLING LOG
Top Bottom
.tea l��l
/
12. REMARKS:
Formation Description
coAes 5-04-4
100 HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCCOROANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND TRAY a COPY OP THIS
: ReCORO NAS 8E PROv1OEO T T E Li. OWNER,
. —6 V2---
SIGNATU ' OF C ` ' TI E LL CONTRACTOR DATE -
PRINTED NAME OF PE
ON CONSTRUCTING THE WELL
l�!
c't
Submit within 30 days of completion to: Division of Water Quality Information Processing,
161/ Mail Service Center, Raleigh, NC 27699.161, Phone : [phone]
RECEIVED 07-11-'12 07 : 36 FROM 9103133102 TO- NC DENR P&S
Form GW.1 b
Rev. 2109
P004/007