405260_Well Construction - GW1_20120521

1. WELL CONTRACTOR:
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
fe,""‘"4
r,
Well Contractor (Individual) Name A •
e.. YIELD (gpm): METHOD OF TEST
/47, (iMp C �. : f. DISINFECTION: Type � Amount
Street Address g. WATER ZONES (depth):
Well Contractor Company Name
azoe
City or Town
7t, Oa, 3
Area code Phone number
SITE WELL ID #(if applicable)
State Zip Code
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# /1/444
OTHER ASSOCIATED PERMIT#(if applicable)] 4
P961.) '44 -
3. WELL USE (Check One Box) Monitoring (Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED Sit av- i
4. WELL LOCATION:
(7lb AleirAN, Pe,....rik la,„
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
y , ,
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.
Top
Ft.
Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom__ Ft. , p ,5d.�. gaN?VC,
: Top Bottom Ft.
Top Bottom
8. GROUT: Depth Material Method
e
: Top t Bottom r Ft. _! a,, i rl ebef4t 1 ' i
Top / ~61 " Bottom Ft. FoOkr
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Top_ Bottom Ft. in. ���'. in.
Top Bottom Ft. in. in.
CITY: 6',, Alt tA..6 e ',f. COUNTYdea)thl,ADIfeeive : Top Bottom Ft in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley elat 0 Ridge ❑ Other
LATITUDE -.3 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 76 71° 3 ' ` -" DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: PS ❑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.)
-4aa
Facility Name Facility ID# (if pplicable)
100 AilfOrk LeA,114 Pefork 'Skid
Street Address
y-dt tit,o,. ge.,uciA., ivsb 020i RP'
City or Town State Zip Code
M. i'(-c-e, ille<-5e, ,t \A .(
(4'
Contact Name
?o3'
Mailing Address
6,‘), frne IA(1,46)1 A. -
City or Town
(910,—) 20-7 SO
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: O pG,
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
: 10. SAND/GRAVEL PACK:
f Depth f ,
Top Bottom la F
Top
: Top
Bottom
Bottom
: • 11. DRILLING LOG
Top Bottom
Ft.
Ft.
Material
Ftti
Size M terial
Formatio Description
• C• .) Ig vti"
/
fu akW,5
State Zip Code
YES ❑ NO (y
/
(Use "+" if Above Top of Casing)
FT.
12. REMARKS:
n I 1
MY 212012
I DO HEREBY CERTIFY THAT THIS WELL WAS.CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECORD HAS BEEN PROVIO THE WELL OWNER.
•
SIGNATURE OF CERTIFIED
L CONTRACTOR
PRINTED NAME OF PERSON CONS
Submit within 30 days of completion to: Division of Water Quality Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
L/607 7IC2
DATE
UCT G THE W L
V D
Imvmorb
Information Processing Unit
ms re,