406632_Well Construction - GW1_20120723

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1. WELL CONTRACTOR:
Well Contra r (Individual) Name
ell Contractor Compen Name
Street Address
/..#4- #0. C., it:)
City or Town State Zip Code
NON RESIDENTIAL WELL CONSTRICTION RECORD
North Carolina DepartMent.of iinvironmont and Natural Resources- Division of Watrr Quality
WELL CONTRACTOR CERTIFICATION # /y9
d. TOP OF CASING IS . / FT. Above Land Surface'
*Top of casing terminated et/or below land surface may require
• a variance In accordance with 15A NCAC 2C .0118.
: o. YIELD (gpm): O METHOD OF TEST
iguLtey,
f. DISINFECTION: Typo Amount
g. WATER ZONES (depth)_
Top , .. Bottom Top Bottom
Top Bottom Top Bottom
Top, Bottom Top Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
Top 4 / , Bottom . d . Ft.,- s 4o _el) Q..
Top BottomFt._ r,..... _
:Top BottomFt.,
(9/ ) 2 ... —/ 577
Area code Phone number
2. WELL INFORAAATION:
CONSTRUCTION PERMIT*
f'
WELL CO E
OTHER ASSOCIATED PERMIT#(It applicable)
/mg-
SITE WELL ID #(if applicable}
3, WELL USE (Check One Box) Monitoring 0 Municipal/PubIIC 0
lndustrial/Commerclal 0 Agricultural 0 Recovery 0 Injection 0
IrrigationOther t0 (11s1 use)
DATE DRILLED /.
8. GROUT: Depth Material
Top Bottom , 0 , Ft. 60(42A
: Top Bottom_ Ft..,,�,„,
Top Bottom Ft,
4. WELL LOCATION: : 9. SCREEN: Depth Diameter
L : Top ,, , Bottom;? 7 . Ft. j)n.
: Top Bottom FL_ n.
CITY: . COUNTYAJec.J I ? Top Bottom FL.in.
TOPOGRAPHIC / LAND SETTING: (cock appropriate box)
0 Slope 0 Valley $Elat 0 Ridge 0 Other
LATITUDE /V,°, ' .70 "DMS OR 3x,xxxxxxxxx DD
LONGITUDE$ )) ° _rD Ay " DMS OR 7 xxXxxxxxx DO
(Street Name, Numbers, Community, sub ►won, Lot No., Parcel, Zip Code)
Latitude/longitude source: OPS [topographic map
(location of well must be shown on a LJSGS topo map andattached to
this forn if not using GPS)
6. FACILITY (Name of the business where the well Is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
/
e. TOTAL DEPTH: 36
b, DOES WELL REPLACE EXISTING WELL? YES 0 NO ir
c. WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
tc.• Y !f w
Mallod
,jix4
.1111111.1,
Slot Site
_WI! in.
in.
In.
Material
ft) G
1▪ 0. SAND/GRAVEL PACK:
Depth Size material
Top BottomFt. ..
Top Bottom FI.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
At) I
/
/
1
/
= 12. REMARKS:
Formation Description
CuAcc' 3O4.01'.
JUL 'G 3 2012
• 100 HEREBY CERTIFY THAT THIS WELL WAS CON8TRUCTf+O IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECOR BEEN PROVIDED TO HE WELL OWNER,
2--
SI ATUR F ER IED WELL CONTRA OR DATE
cYjd#K-5
▪ PRINTED NAVIE OF'PERSON CONSTRUCTING THE WELL
RECEIVED
Submit within 30 days of completion to; Division of Water Quality • information Processin E 07-6300 �, dorm Cw-� b
Y P � �a ��i�3ev.2109
1817 Mali Service Center, Raleigh, NC 27699.161, Phone : (919) 6
RECEIVED 07-14-'12 08:11 FROM- 9103133102.
Information Processing Uri TO- -NC DENR Lr /BOG • . P011012
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