405444_Well Construction - GW1_20120605

RED JUN 0 5 2012
d
A E Efi E !kr L JELL cr sr ,.rtoo:: 11 REC „„„
North C....:aroiitta Department of FA,/ ironment and Natural Resource5- Division or Water Quality
1, WELL CONTRACTOR:
2./.9
Well Contra .or (Individual) Name
ELL COUCT(ZDJR CRTtUTcCfr&TjJON
Well Contractor CompanyL.
Name
Street AddnaSS
)40
City or Town
%) ) 5- 9 Et)
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT-8
OTHER ASSOCIAT8D PERMIT g(if epoit-weLP A
SITE WELL ID thil &Plowable)
State
Zip Code
3. WELL USE (Cher* One Box) Monitoring 0 MunicipaliPutofic 0
Industrial/Commercial a Agricultural 0 Recovery 0 Injection
Irrigation Other 0 (list use)
DATE DRILLED_1
4, WELL LOCATION:
; di. TOP OF CASI44WG IS i FT. Above Land Surface°
°Top of casing terminated at/or below lend surfac.,e may require
a variance in accordance riIth 15A NCAC 2C ,0116.
a. YIELD itiplaq•
a METHOD OF TEST
t. DISINFECTION: Type Agiourit
TIATER ZONES (depth):
Top Bottom Top, Bottom ,
Top Bottom_ Top Bottom
: Top Bottom Top Bottom
: 7, CAZINGt Depth
Top 1- Bottom
DiamMv
0, 0 a
Top Bottom
Top Bottom
Ft,
Ft,
ThIckne-gal
Weight
51e.A.„4 6
t3. GROUT: Depth Material Method
Top 0 Bottom Ft. e to- diaXtr.
: Top Bottom Ft.
Top Bottom. Ft.
9. CREEN: DeptDia= r lot te
(Stnsei ame, Numbers, Community, SubdI
on, Lrei M, Parcel, Zip Code) = Top Bottom Ft. in. In. Wel
Sh SS
Topa Bottom_A„,, Ft.In. in.
CITY: COUNTY : Top Bottom Ft, in. in.
6
TOPOGRAPHIC / LAND SETTING: ((Ilea( appropriate box)
C.:) Slope [Valley lid tat °Ridge 0 Other
LATITUDE ,^51e ' '1 DMS OtO 3X.XXXXXXXXX DD
LONGITUDE 7,'; 6 i'}°1113r " DMS O DD
Latitude/longitude source; 1%. PS °Topographic map
(location ofwell rriutil be so on e USGS topo map anclanched to
this form if not using GPS)
5, FACILITY (Name of the boainess where the well Is located.)
cJ
Facility ame
Street Address
City or Town
Contact Name
Mailing Address
City or Tawn
L•••••••.'....•••••••••••..)
• 1 5'
Facility IDS (if applicable)
State
Zip Code
Area code Phone number
G. WELL DETAILS:
a, TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING
o. WATER, LEVEL Beim Top of casing:
State
Zip Code
ELL? YES 0 NAL
(Use "..-° If Above Top of Casing)
1.SAND/G
VEL PACK:
,,tr?
Size Material
: Top Bottom Ft.
Top Bottom Ft.
: Top Bottom Ft,
11. DRILLING 1.,0Q
Top Bottom
• ,25)
1
1
12. REItliARKS:
Formation Description
DO HERE CERTIFY Tc-IAT THIS WELL WAS NSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION VA RD AND THAT A COPY OF THIS
RECORD HAS BE PROVIDED TO THE is Ow eA,
SIGNAT
E OF E. IFIED EL NTRACOR DATE
PRINTED NAME OF PERSOV CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of 'Ater uafl
1617 Mall Senile Cenov, Raleigh, NC 27609-101, Phone (1O) 607-0300
1.*
4,1
• 7
Information Proceseino,
Foim GW-lb
Rev. 2/0g