405437_Well Construction - GW1_20120605

i. WELL CONTRACTOR:
WII Con
RECD JUN 0, 5 2012
h,„1) ELL C:ONSTRU 11 'NI [P,1.". 'ORD
•
r
L. . - t•
NiJi Camlina Npartinfot of Environment and Natural Resources- Division of tii/ger Qudity
WELL CONTRACTOR CEETWCA.TON
ctor (Individual) Name
Well Contractor Company Name
eaL__
Street Address
.044'
City or Town
) 35
j
Area code Phone number
•2. WELL ONFORMATVON:
WELL CONSTRUCTION PERMITit
OTHER ASSOCIATED PERMITO(if applicable)
69TE WELL ID Vet(if eptadicebte)
3.
State
Zip Code
Municipal/Public 0
induellialiCommercial 0 ',Arley/turas 0 Recovery 0 injection 0
Irrigation Other 0 (list use)
DATE OPULLED
4. WELL LOCATION:
ELL USE (Check One Box) Monitoring 0
‘f4 _ '7-Re&
(Stet Nam, Nurn.1-6, Comrnorifty, Sue:040K Lc4 No., Petal, Zip Code)
CITY: COUNTY.."}cor
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
0 Slope OV&ley r3t 0 Ridge 0 Other_
LATITUDE X...14 °9 DMS OR 3X...XXXXxXXXX OD
LONGITUDEA " DMS OR 7x,xxgxxx24 DD
Latitude/longitude source: [Topographic map
(location of well must be shown on a uSGS Popo map andattached fo
this form if not using GPS)
G. FACILITY (Name of the business where the well is located.)
c).0
Facility Name
Street Address
City or Town
Contact Name
Facility I
tie(
(if applicable)
State
Zip Code
mailing Address
- 4=V.AWZfz.wer.r.---
City or Town
State Zip Code
Area code Phone number
WELL DETAILS:
e. TOTAL DEPTH:
b.
OES
ELL REPLACE EXISTING WELL? YES 0 NO
a. WATER LEVEL Ookm Top of Casing:
(Use '80.° if Above Top of Casing)
FT.
Submit withOn 30 chilli of completion to: Division of
1617 ail Service Center, Raleigh, NC 2700461, Phon
\./
a3. TOP OF CA8ING IS „., FT. Above Land Surfaog°
'Top of casing termi eted et/or below land surface may require
a varlanco In acaordance with 15A NCAC 2C .0118.
(EP. YIELN (gioovo): 0 METHOD OF TEST
q. DISINFECTION:: Tyro Amount
g. WATER 2ONES (depth):
Top Bottom Top _ Bottom
Top Bottom Top Bottom,,,
Top Bottom„ Top Bottom
T70. pCrt . Aelr 810:32z.
Top_ Bottom_
Top Bottom_
8, GROUT: Depth
Top,,,,2_ Bottom
Top_ Bottom
Top Bottom
e. SC EEN: ifroptti
Top 30 Bottom ir.t)
Top Bottom
Top Bottom
Ft.
Material
ThfIckng)1
toWel'ht
,1,
Dia ter Slot SLIe
Ft. in. Cite
Ft. in,
Ft. in.
: ID. SAND/GRAVEL PACK:
Dept Size
Top Bottom Ft,
Top Bottom FL
:Top Bottom R.
: 11. DRILLING LOG
Top Bottom
/
12. REMARKS:
tre
itgria0
m;.thod
tvla
Materiol
Formation Description
e0.4.62S
AV 9 A 9 p
J
; I DO HEREBY CERTIFY THAT THIS WEl.l. WAS.CON6TRUCTED IN ACCORDANCE WITH
IBA NCAC 70. WELL CONSTRUCTION STANDARDS, A u THAT A COPY OP TH1$
RECORD HAS BEEN P DEC TO THE WE sW
SIGNATVR' 'OF CE FIED 113'(LL P.N.ACThF DATE
ce_.5
PRINTED NAME PERSON CONSTRUCTING T)-I WELL
ater *tali
MP) Et14300
inf
motion ProcesgIng,
Form GW-lb
Rev. 2/00