407844_Well Construction - GW1_20120913

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4183-A
1. WELL CONTRACTOR:
Michael Paul Brown
Well Contractor (Individual) Name
Mad Dawci, Inc.
Well Contractor Company Name
1006 Camp Creek Rd.
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28080
State Zip Code
N
OTHER ASSOCIATED PERMIT#(if applicable) it)A.
SITE WELL ID #(if applicable) fY1 , S
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED Cs g /3 /a 0 Z
4. WELL LOCATION:
7336 Airp,e1-4
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: tat\inn, bYs COUNTY MeAN) a.n 00c1''
TOPOGRAPHIC KAND SETTING: (check appropriate box)
❑ Slope :Walley Flat ❑ Ridge ❑ Other
LATITUDE • 3g °) ' SAS "DMS OR 3x.XXXXXXXXX DD
LONGITUDE 4i 17 ° f ' 6$3 "DMS OR 7X.XXXXXXXXx DD
Latitude/longitude source: OGPS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
eare_c
Facility Name Facility ID# (if applicable)
'I 33, Co 1iNe S
Street Address
wikm`‘vkkkek. t ai(L1O.3
CityTown or State Zip Code
ts,)VA e
Conta t Name
U,00 tc\ M:ktc RazV, 17- c
Mailing Address
ie1p ‘kt
City or Town
) &.1t.1 'ISoS-
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
'JC -1st
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 i6 ❑
c. WATER LEVEL Below Top of Casing: /M FT.
(Use "+" if Above Top of Casing)
072)4
d. TOP OF CASING IS 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 (gpm): tJ A METHOD OF TEST L A
f. DISINFECTION: Type IQ A
Amount 1U
i g. WATER ZONES (depth):
Top S -+ Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top Bottom
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 3 Bottom LI Ft.
Top 0 Bottom _ Ft.
Top Bottom Ft.
9. SCREEN: Depth
Diameter
5 Ft. of
Thickness/
Weight Material
.1dig.(2
QcIC
Material Method
&Mom viC Po u r
Pbok\o,Ack (out -
Diameter
Slot Size Material
Top _5 Bottom 1.5 Ft. p� in. - 0)0 in. PVC
Top Bottom Ft. in.
Top Bottom Ft.
: 10. SAND/GRAVEL PACK:
Depth
Top L Bottom IS
Top Bottom
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
•
—�1 10
/ i<
/
12. REMARKS:
VOA(
in.
in. in.
Size Material
Ft. / /O Si) i.:
Ft.
Formation Description
Z\beck 'ti c d ‹....c)
wS.���
,r,b A tee S k,Je
_j
12)
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C •` NSTRUCTION STANDARDS, AND THAT A COPY OF THIS
. RECORD S BE .��� VIDEO TIE WELL OWNER.
ATURE • F CERTIFIED
ELL CONTRACTOR DATE
: Michael Paul Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
J,z
Submit within 30 days of completion to: Division of Water Quality . Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161 Phone [phone]
Form GW-lb
Rev. 2/09