405259_Well Construction - GW1_20120521

NNRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
I ill/A-144 e
Well Contractor (Individual) Name )
L
)100(7 (64,14 re4:, v-t)
Street Address
Well Contractor Company Name
Latitude/longitude source: 3PS ❑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.)
5r,:_eyf,e trutA, ":7467;?
FacRy Name Facile ID# (i applicable)
Co1f)1Lt, Lake, (,, f yr .
Stre Address
Vh6,41k, g-etti*' itte_d /47246.,V
City or Town
P19:
Contact Name
I t erI-1,
State Zip Code
Mailing Address
/i:z#i j&jA/
City or Town
( tO ) e:(?0 glO
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 1' c
v_ 67ev?-55
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Below Top of Casing: -7 FT.
(Use "+" if Above Top of Casing)
0 9
d. TOP OF CASING IS 0 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
• a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: ype /'f Amount
g. WATER ZONES (depth):
(YLA-`'1. • To / Bottom Top Bottom
City or Town State Zip Code
23oa3
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# c\-/
OTHER ASSOCIATED PERMIT#(if applicable) IV ik
SITE WELL ID #(if applicable) /11461.)
3. WELL USE (Check One Box) Monitoring E J"Municipal/Public 0
Industrial/Commercial 0 Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED -
Top / Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
: 7. CASING: Depth i Diameter Weight Material
Top 6 Bottom 07 Ft. (9,r,►y t) ?V6,
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
it
Top ei Bottom '• Ft.
Top Bottom ; Ft.
Top Bottom Ft.
4. WELL LOCATION: = 9. SCREEN: Depth Diameter Slot Size Material
4'60 Lke)x kk e )idL : Top Bottom Fr Ft. in. in Ft
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
f Top Bottom Ft. in. in.
CITY: \ 1 k \AA e el A COUNTY . )e,,, ,Pfoig v ; Top Bottom Ft. in. in.
TOPOGRAPHIC / LApo SETTING: (check appropriate box)
❑ Slope [Valley nelat ❑ Ridge DOther : 10. SAND/GRAVEL PACK:
3't
LATITUDE C° o2 ' r S " DMS OR 3X.XXXXX) xXX DD :
Top a Bottom , Ft. /4/ GAY.
LONGITUDE ?? °53 ' 4 . " DMS OR 7X.XXXXXxxxx DD
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formati n Description
: / �'
1
1
/
/
/
12. REMARKS:
MAY 21 ZOI?
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 PROVID D • THE ELL OWNER.
Pc- ECEIVED
PRINTED NAME OF PERSON CONSTR
SIGNAT RE i F ETIFIED ' LL CONTRACTOR DATE
•
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mali Service Center, Raleigh, NC 27699-161, Phone : [phone]
MAY _',.1
1 • E! 2
Form GW-1 b
Information Pr8eWsPia Unit
DWQ/BOG