407843_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 Dawa, 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
OTHER ASSOCIATED PERMIT#(if applicable) 1JA
SITE WELL ID #(if applicable) 1 NO •
3. WELL USE (Check One Box) Monitoring ly Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation ❑ Other 0 (list use)
DATE DRILLED V 2 3 a C l
4. WELL LOCATION:
33t, rnaru,64-
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: tAJi iryo .4Q COUNTY New tiart0Ver
TOPOGRAPHIC ND SETTING: (check appropriate box)
❑ Slope [Walley [Flat 0 Ridge ❑ Other
LATITUDE * 3q° 16 ' t 0 a " DMS OR 3X.XXXXXXXXX DD
LONGITUDE AP 77° LI' 413 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: Vi3PS ['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.)
ferS
Facility Name Facility ID# (if applicable).
7.?.34) ArG-' S�
Street Addres
t.,'f ► r h C Rig03
City or Tovtl State Zip Code
.S�4ple 11)A:1e
C tact Name
!/Oo Aritvte4erP&e(' Vr
Mailing Address
('rrejv;)Ie oeir
City or Town
( cI! ) (D/ - /COS'
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
,VC D7'W
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ N0<5
c. WATER LEVEL Below Top of Casing: Aft)
(Use "+" if Above Top of Casing)
FT.
A n .r, 0 A
0 (1. is
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):
METHOD OF TEST kj �
f. DISINFECTION: Type 10 IA Amount it) A
g. WATER ZONES (depth):
Top '13, Bottom Top Bottom
: Top Bottom Top Bottom
: Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom Ft. P'l SC% LIO PV C
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material PourMethod
Top Bottom Ft. cr4on r 4
3 e
Top 0 Bottom 3 Ft. POC4 ctin•A VO4C
Top Bottom Ft.
9. SCREEN: Depth
Diameter Slot Size Material
• Top 5 Bottom / S Ft. o�
Top Bottom Ft.
Top Bottom Ft.
: 10. SAND/GRAVEL PACK:
Depth
Top Bottom I .5- Ft.
▪ Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
fes/ ►n
: _4_111 15
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12. REMARKS:
in. • O l a in. Pv e
in. in.
in. in.
Size Material
0 4'0 5!' lit f i
Formation Description
efetyd' hick �w d
� s
k 't Red 5&,, cI
cet 4 R cxi .1
rie
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, . TRUCTI • TANDARDS, AND THAT A COPY OF THIS
: RECORD H IDED WELL OWNER.
SI £TU
• Michael Paul Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
F CERTIFIE WELL CONTRACTOR
2 3 /2
DATE
•
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