406633_Well Construction - GW1_20120723

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1. WELL CONTRACTOR:
NONRESJDENTJAL WELL CONSTRUCTION RECORD
North Carolina Dcpanrnent orJ nvironment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
G4b&, ZY,
Well Con for (Individual) Name
city or Town
V11ell Contractor Company Name
Street Address
6 5'
r-/ 9P7
Ares code Phono number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT* /M.
OTHER ASSOCIATED PERMIT9(It applicable) ft.��- _
#}'Ct
SITE WELL ID #(if epplicadeL
3. WELL USE (Check One Box) Monitoring 0 Munlcipa$/Pubiic p
Industrial/Commercial 0 Agricultural 0 Recovery 0 lniection 0
Imlgation then 0 (list use)
DATE D ILLED
4. WELL LOCATION:
State tip Code
,.
(eta Nome, urnbere. Community,
CITY: CO_
7. CASING: 0opth Okamoto
Ton 44 , Bottom 0
Top Bottom Ft.
Top ..�, BottomFt,
8. GROUT: Depth Material
Toae, Bottom jQ F(.
Top Bottom____,_ Ft.
Top_ BottomFI.
9. SCREEN: Depth Diameter
.
• -- : Top d oottom3r _
• TopBottom Ft• . Vy in.
COUNTY MJkifK: Topes Bottom Ft. In.
TOPOGRAPHIC / LAND SETTING: (check appropriate OOX)
Q Slope C1 Valley J Flat Q Ridpe O Other._,,
LATITUDE °1 > DMS OR 3x.xxxxxx*xx OD
LONGITUDE " DMS OR 7X.XXXXXXXXX OD
Latitude/longitude source: PS [Topographic map
(location of well must be shown on a U563 ropo map andattaohed to
this form if not using GPS)
6. FACILITY (Name of the business where the well is located)
id4"
Facility Name
Facility ID# (if applicable)
AMMIMMINEMIWO
Street Address
City or Town
State
Zip Code
Contact Name
Mailing Address
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:S r
b. DOES WELL REPLACE EXISTING WELL? YES Cl
State Zip Code
c. WATER LEVEL Below Top of Crleing:
(Use '-*' IT Above Top of Casing)
G._
NO AI(
FT.
fve-
Method
L.
Slot Size Material
d_e_d In. ,L1
C„y
in.
in,
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom FI.
Top 9ottomFt.
Top Bottom Ft,
: 11. DRILLING LOG
Top Bottom
, e / o
/
12. REMARKS:
Formation Description
( r)APJ -,"'4
JUL 2 3 2012
I DO HEREBY CERTIFY THAT THIS
- 'SA NCAC 2 , WELL CONSTR CT
RECORD BEEN PROVI
= SIG
TORE ' C R ' 1
PRINTED NAME
ELL WAS CONSTRUCTED IN ACCOROANCE WITH
STANDARDS, ANO THAT A COPY OF THIS
THE WELL OWNER.
(fp *-2.C.L2----
ED WELL CONTRACTOR DATE
PERS
s
N CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality • Information Processin
"(3
d. TOP OF CASING 1S M P1'. Above Lend Surface*
'Top of casing terminated al/or below lend surface may require
: e variance in scoordanoo with 1SA NCAC 2C .0118.
o. MELD (gprn): 4', METHOD OF TEST IA +,4'
t. DISINFECTION: Typo Amount
g. WATER 20NES (depth):
Top Bottom Top Bottom
: Top Bottom
Top Bottom Top
Top
Bottom
Bottom
Thickness(
Weight Mvtariel
DOiviaion, La No,, Parcel, zip c000)
161 T Mall Service Center Raleigh, NC 37:RECE1
088 1 a1 Phone [phone]
RECEIVED 07-14-'12 08:11 FROM- 9103133102
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W-1b
JUL I 6 2012
TO- NC 1 Pt:., Processing ur=P012/012
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