404488_Well Construction - GW1_20120423

N ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-ac.)5.c?
Division of Water Quality
ON #
WELL CONTRACTOR CERTIFICATI
1. LL CON CTO
�AuCC. ReaN
W C rac or (Indi ' u 1) NamAAe
`OPtt
, 'TUC
W II Co actor Com nv Name
i
Str et Address
bfcoLt (k "e,.
City or Town
(3% \ S77?97D
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
93050
State Zip Code
tcr
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring i( Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
3- 9.149,
DATE DRILLED
4. WELL LOCATION:
9'M `oL CAl' 2cL a.?stto
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: (it-) t I(Niti`'k 4° 16,)
COUNTY W Ro"e
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
oSlope ❑ Valley Flat DRidge ❑Other
LATITUDE pi° 41 ' ct,pcm " DMS ORS WleM DD
LONGITUDE77 ° 647' 211, " DMS OR AgRgiatommx DD
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.)
C. wialelAOtioe. rriuc.
F cility Une tt . Facility I
M 6 AZl I f f (5eACY\
C.
Street Pfldress
(A) t ( M, t i1/4.)510 P P.0 t
Cr or Town
Votto i e. afte,bbu.p.
IIP
State
(if applicable)
difil°i
Zip Code
ontact Nkme
V.0 . % ' l C�
Mailing Address
CccW' JC ,
City or Town
(76�t) 7'5'9,- Ici&
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 1 S.o
9.8 oai - 0
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑,/
c. WATER LEVEL Below Top of Casing:
NOX
FT.
(Use "+" if Above Top of Casing)
Ttilltgq
r rt•
d. TOP OF CASING IS fal%A.3 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: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
•
Thickness/
7. CASING: Depth Diameter Weight
Top ° Bottom 5.°
: Top Bottom
Top Bottom
8. GROUT: Depth
Top ' Bottom a` 0
Ft.
Ft.
Ft.
Material
g.., jW0 Poi...
Material
Ft. COP c
Method
-r pie irne
Top a' (> Bottom II' ° Ft. aRioiopete T ' v" 1 e
Top Bottom
9. SCREEN: Depth
Top 5.° Bottom I5•0
Top Bottom
Top Bottom
Ft.
Diameter Slot Size Material
Ft. in. • b in Q\JC
Ft. in. in
Ft. in. in
: 10. SAND/GRAVEL PACK:
Depth Size
Top q � Bottom E 5,0 Ft. St. 9"
Top
Top
: 11. DRILLING LOG
Top
•
•
•
•
•
Bottom
Bottom
Bottom
/ 6"
/ I 5.0
/
/
/
/
tt,\,? ?.\
•
•
\T '.00e
12. REMARKS: NtrAd" !`-' '
Ft.
Ft.
Mater•.iajr.
5(41,�,
l
p f
Id APR 232012
Formation Description
Gg>eL
SAfr)ct,
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
. RE D HAS B PROVIDE O THE WELL OWNER.
3 ". a? k2
SIGIATURE OF C RTiFIED WELL CONTRACTOR DATE
(40 CC C• GAR-abt-3
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1,D
P qi7 rE 1-11
) fi r' p
1 f� lliij
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09