405256_Well Construction - GW1_20120521

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # c'q
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
itylvc- G D �•.,,. �" ° 1.
Well Contractor Compar6i Name
C
Strefr.t.Address.
City or Town
( ?(,) 77Z eZ- (-7
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) f,
SITE WELL iD #(if applicable) 1� r Li —sr
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Imgation❑ Other ❑ (list use)
DATE DRILLED cf f
4. WELL LOCATION:
cs'Oo `"or . 6� ., Pr,- A, if"
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: c- �. I:,r,o �= � COUNTY ktiL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope [Valley D Flat ❑ Ridge DOther
LATITUDE !' °' . . ! " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 1157 ° 3 ' 43 f f 7 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: E GPS ['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.)
Facility Name
Facility ID# (if applicable)
Street Address
City or Town
Contact Name
4' 8
Mailing Address
r�
� 1,4... •
City or Town '�
( ci c' ) Q'7C'
Area code Phone number cs
6. WELL DETAILS:
a. TOTAL DEPTH: / '
)3 e ,
dic v
State Zip Code
b. DOES WELL REPLACE EXISTING WELL?
te—
State Zip Code
YES ❑ NO ❑
c. WATER LEVEL Below Top of Casing: 7
(Use "+" if Above Top of Casing)
FT.
d. TOP OF CASING IS 0 FT. Above—Latid'S a
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): fulf METHOD OF TEST
f. DISINFECTION: Type './r Amount
g. WATE ZONES (depth):
Top s Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth f Diameter Weight Material
Top 0 Bottom 1 Ft. 2-
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material i•a r, Method
Top Bottom 1- Ft. I")., r 0.�► �' - c,
a �e B
: Top 1 w u• Bottom 1- Ft. 1)
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
a Top ' .. Bottom 2e Ft. .Z in. ` in.
Top Bottom Ft. in. in.
: Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top `7. Bottom / 2 z Ft. 2, N
Top Bottom Ft_
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
0 / i
/
/
/
/
/
12. REMARKS:
MAY 212012
1 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 PROVIED O THE WELL OWNER.
SIGNATURE OF C - RTIFiED WELL CONTACTOR DATE
PRINTED NAME OF PERSON CONST
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
MAY
t , 2012
information Processin Form GW-lb
Formation Proce ii 2Mit
DWQ/BOG