405442_Well Construction - GW1_20120605

REC'D JUN 0 5 2012
CONSTRUC . OON RECORD
• .
Noith Carolina Depariment of' Environment and Natural RO5Ovirces- Division of Water QuaJy
WELL CONTRACTOR. CERTEFDCALTDON
1. WELL CONTRACTOR:
Well Cadractor (Individual) Name
a A CA2-•
VA/ell Contractor Company Name
_4" f>
Street Address
City or Town
Area code Phone number
2- WELL ONFOR;14.NTbON:
WELL CONSTRUCTION PGRMITg
er‘ft5
state Zip COS
OTHER ASSOCIATED PERMIT(it p Ica ble),ZA___
Sift WELL ID g(if
3. WELL USE (Check One Box) Monitoring a Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 injection 0
Irrigation:h Other 0 (list use) ,
DATE DRILLED
4.
ELL LOCATION:
(Street Name), Numbers,
CITY:
unity, -gIbdivisioli, LA No., Parcel, zip Coda)
COUNTY et..).0.4?
TOPOGRAPHIC / LAND SETTING: (check approprie-te bo)()
C3 SloPe °Valley 11: let th
0 Ridge 00er
LATITUDE 34'34 ° . ) " DMS OR 3X.XXXXXXXXX DD
LONGITUDE lig 'V) $o 1_19 " OMS OR 7x.xxxXXXMX DD
La.tJtude/Iongitude source: PS ErrOoographic map
(location of well must be shown on a USGS typo map andatteched to
this form if not using GPS)
G. FACILITY (Name of the business where the well is located)
cfc-
Facility Name
Street Address
Facility ID# (if applicable)
City or Town
State
ZIp Code
Contact Name
Metiling Address
City or Town
Area code Phone number
5. DETAILS:
a, TOTAL DEPTH:
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
e. WATER LEVEL Betow Top of Casing:
(Use '4.* if Above Top of Casing)
FT.
•
d- TOP OF CASING IS 71-- FT. Above Lend Surface°
clop of casing terfninated alior below land surface may require
a variance in accordance with 15A NCAC 2C .0116.
a, YtEL (goll): _filf.g.;; METHOU OF TEST e6A.p.v.
f. DISINFECTIOlki: grype Amount
• 0, WATER ZONES (depth):
Top Bottom Top BottOm
Top_ Bottom Top Bottom
; Top Bottom Top Bottom
7, CASING: Depth Diameter
ToP421L. Bottom,3
-
:., Top Bottom Ft.
-: Top Bottom _ Ft.
B. GROUT; Depth
Top Bottom c' Ft.
: Top Bottom FL
Top Bolton" rt.
9. SCREEN: Depth Diameter It Sias Material
Top_1Bottom ea Ft. /14' in, in.
Top Bottom Ft. in, in.
Top Bottom FI. in. in.
Thian al
Weight Materiel
qr.
Method
: 10, SANDIGRAVEL PACK:
Depth Size
Bottom Fl.
Bottom Ft.
Bottom Ft,
: Top
Top
Top
1 . DRILLING LOG
Top Bottom
Material
./10.
C)
ectsesair=aa
12. REMARKS:
tiatarlat
Formation Description
2fip
I DO HEREBY CERTIFY re -{At THIS WELL WAS CONSTRUCTED IN ACCORDANCG WITH
• ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVID p TO T WELL OWNER,
I A R•FC IF WELL CONITFIACI
5--
DATE
PRINTED NAME OP PERSON CONSTRUCTING THE WELL
Sutomlt within 30 days of completion to: ovimion of `,rmigiter Quality Information Pr
1617 ale Servbce Cantor, glage6gh, NC 27899.161, Phone : [phone]
cessIng,
Form GW-lb
Rev. 2/09