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HomeMy WebLinkAbout405260_Well Construction - GW1_201205211. 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 : (919) 807-6300 L/607 7IC2 DATE UCT G THE W L V D Imvmorb Information Processing Unit ms re,