HomeMy WebLinkAbout405499_Well Construction - GW1_201206051. WELL CONTIUCTOR:
Well Contra
_Ai
REM JUN �5 2012
2,71-1-71NT 1/1, ILL C3NWUCJllONIFCWU
North C„Eirolioa Department of Environramt and Natural Resotarms- Division of Water Quality
WELL CONTRACTOR CE.1111NCATION
ifLtJ
r (Individuai) Name
el Contractor Company Nam1
• Street Address
CA 2,1AL___
—.—
City or Town
3 r 7 VI_
Area code Phone number
2. WELL INFORMA11
WELL CONSTRUCTION PERMIT____
OTHER ASSOCIATED PERMIT -Nil evpliovibte)
SITE WELL ID e(ii appiscapi
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public
Industrial/Commercial 0 Agriculturst 0 Recovery 0 injection 0
Irvigationge6ther 0 (list use)
DATE
4. WELL LOCATION:
t e
(Streit NWT*, Numivra, Community, Subli
CITY: 0.„) • 1,445,
on, LCA Ni., Parcel, Zip Cade)
•
: de TOP OF CASING IS I- 1 FT. Above Lard SurSaca°
°Top of casing terminated at/orbeow fend surface may require
, a variance In accordance with 15A NCAC 2C .0113. .
: er YIELD (gperin): ..6...c____D METHOD OF TE8L194)--FIP
DISINFECTION: Ty ArnOlint _
ig. MATER /ONES (depth):
..
______42__ -la' 9. 45 : Top Bottom
. - VA...
State Zip Code : Top Bottom
: Top
: 7. CASING: Depth
Top 1--• ( Bottom
: Tog, Bottom
Top Bottom
8. GROUT: Depth
Top
: Top
Top
10
Top Bottom
Top Bottom_
Bottom Top Bottom
Thick- kned
Ft,
F.
Ft.
Diantega? Vvolght tiktreal
Material
(3 Bottom 3 0 Ft,,ZZO
21.9.1.,,tato.
Bottom Ft,
Bottom Ft.
S. SCREEN: Depth Olarrtetet. Slot Sligo
Top e,:-L Bottom 40 Ft. ,/ Yelf In. Off°
Method
ke4e-
Top Bottom Ft. In. in.
COUNTY A ) (4) if4MfuN -op Bottom Ft.
TOPOGRAPHIC LAND SETTING: (check appropriate bog)
0 Slope 0 Valley la 0 Ridge [71,, Other
LATITUDE az 9 'If •DMS OR 3X.XXXXXXXXIt DD
LONGITUDE;81)) DMS OR 7x,XXXXXXgXX DO
Latitude/iongltude source: i`h% PS OTopograpnic map
(location of well must be ahiwn on a USGS topo map andattached to
'Ns form if not using GPS)
G. FACILITY (Name of be basIness where the well is located,)
Facility Barrie
Facility ID# (if applicable)
Street Address
City or Town
State Zip Code
Contact Name
Mailing Address
City or Town
Area code Phone number
. WELL DETAILS:
0. TOTAL DE.PTH:
WVA 0401^1,
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATE LEVEL Below Top of CaaIng 1 trlf FT,
(Us *-0 if Above Top of Casing)
I (1. BAND/GRAVEL PACK:
Depth
: Top
Top
Top
: 11. DRILLING LOG
Top Bottom
'2t
in. REMARKS:
Metar
in. In.
SI2e
Bottom Ft,
Bottom Ft.
Bottom •
Ft,
tty
Formation Description
A
A.)
: DO HEREBY CERTinr Ti-kA't THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
16A NC2CWELL .10 . • t CiiON STANDARDS, AND THAT A COPY OWTHIS
- AC , C
REC. II
HAS BEEN '!1.1,1 V TO 'THE WELL OWNER.
5 ,
TIFIED WELL C6WTRACrair DATE
PRIN EO NAME OF RSON CONSTRUCTING THE WELL
Submit w in 30 days of compOotion to: Divon of Mur �u&ty nformation Process!ng,
IEIT man SeMce Center, Roleigh, C27699-le1, Phone Me) 807-6306
• Form GW-ft.)
Rev. 2/09