406623_Well Construction - GW1_20120723

1. WELL CONTRACTOR:
Wall Contra r (individual) Name
Snot Address )$9
or own State Zip Code
'‘,0 , (2---0
NON.RESJDENTIALWELL CONSTRUCTION RECORD,
North Carolina Department o f Environmesnt and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2.)
. d. TOP OF CASING 13
FT. Above land Surface'
'Top of casing to ted etlor below Land surface may require
a variance In accordance with i 5A NCAC 2C .0118.
�... : e. YIELD (gpm): 4 If METHOD OF TEST
I. DISINFECTION: type, ._ Amu
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
- Top Bottom Top Bottom
Thickness)
c
43/41) 31r- /9 (9
Area code Phone number
2. WELI. INFORMATION:
WELL CONSTRUCTION PERMIT ',Li --
OTHER ASSOCIATED PERMIT#(it macaw)
SITE WELL IO tkit appfiaaeL
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public p
Industrial/Commercial a Agricultural 0 Recovery 0 In)ection 0
Irrigation° Other 0 (list use)
DATE DRILLED
7. CASING: Depth Diameter Weight Material
Toq.� 8ot6om24,_ 5—C-L—k4 /VC'
Top _ Bottom - Ft.
Top Bottom Ft.
= B. GROUT: Depth
'fop 40 Botto 'L Ft.
: Top Bottom Ft
topBoom FI.
Material
Method
"e."
4. WELL LOCATION: 1: 9. SCREEN: Depth Diameter Slot Size M*tsrlal
3 ,A E+ : Top_ Bottom ..- Ft )1 y In. 610 in. ,i) ct-
in.
In.
(Street Neme, Numbers, Community. Subdivl . Lai No., Pawl, by Code) ; 'fop Bottom Ft in.
CITY: /op COUN Y : Top__.. Bottom.,,,..._... Ft._--- in.
TOPOGRAPHIC I t.AND SETTING: (check spproix1Mte x)
O Slope O Valleyf lot C7 Ridge O Other ,..
LATITUDE °, :, 4,1 C " DMS OR 3x.xxxxxxxxx Do
LONGITUDE prreft lir ` DMS OR 7iiiaMocxxii. DO
Latitudellongltude source: OOPS OTopogrephlc map
(location of well must be shown on USGS topo map andattached to
this form If not using GPS)
6. FACILITY (Name of the business where the well is located.)
Facility Name
Facility ID* (It applicable)
Street Address
City or Town - State Zlp Code
Contact Name
Mailing Address
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAI. DEPTH:
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOP(
c. WATER LEVEL Below Top of Casing: /9 FT.
(Use'+` If Above Top of Casing)
1▪ 0. SANDIGRAVEL PACK:
- Depth Size Materiel
Top Bottom. Ft.
Top Bottom,_,____
Top Bottom Ft,
: 11. DRILLING LOG
Top Bottom
424
"57/
1
= 12. REMARKS:
•
Formation Description
43 2012
• 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
- 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED T• HE LL OWNER.
SIGNAT ' E 0 ERTI j � � Ll CONTRA OR DATE
PRINTED NAME OF P SON CONST��11�'�E���D
'ubrnit within 30 days of completion to: Division of Water Quality - Information Processing, ZW,owg'm
Mail Service Center, Raleigh, NC 27698-161, Phone : [phone]
rECEIVED 07-14-` 12 08:11 FROM- 9103133102
TO- ., cProc�goessing Li�002/012
IBC