403635_Well Construction - GW1_20120319

IVONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Wat r Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
(V) t
'�...�
r,
„..).
IS .4- FT. Above Land Surface*
d. TOP OF CASING
)C-
• ▪ *Top of casing terminated at/or below land surface may require
Well Contractor (Individual dame /'`'� • a variance in accordance with 15A NCAC 2C . 118. 4.\ r: ( i iftit\ JLM,(,(S r_ 4
'' • e. YIELD m : I -.:1 METHOD OF TEST I
: f. DISINFECTION: Type , 6 1 .. Amount
Vyell ontr ctor ompan ame
T' Street A r ss
City or Town
C"),'
fNctate
f 14(
4
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
SC/.
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Coma. ercial ❑ Agricultural ❑ Recovery 0 Injection 0
Irrigation) i Other ❑list usse)
DATE DRILLED
4. WELL L CATION: , .
1--tal --),, Lttevri ie S. C.'-'i)
(Street Name, Numbers, Community, Sub ivi ion, Lot.No., Parcel, Zip Code)
� r '
..
CITY. t. c: 5‘vi.1)(;,'..
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
0Slope ❑Valley [Vat ❑Ridge ❑Other
LATITUDE 36 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75
" DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: [BPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY,.(Vame of the busine s where the well is located.
(:)A CA �-
Facility iame
LL
A 1Ni net
F ility�,
(if applicable)
Street, ress s:
k kki*Yi'DV 1 e. 15-cte6.---
City o Town
tyeth n
State
Zip Code
ntac Nair(e ve
Mailing Address + rig
r . . +T\i—
obj.
City_or Town cl..)1- ci
_
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0
State
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
l
Zip Code
NO
FT.
•
•
: g. WATER ZONES (depth
: Top— ', Bottom, ' Top
: Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
ter&
; Top +1.Bottom �.� Ft. �� 1
. Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top () Bottom. W-• 3 Ft.
Top--, Bottom—, Ft.
Top Bottom Ft.
9. SC EEN: Depth 4..
Top--, ;� . Bottom....
- Top Bottom
%. ; Top Bottom
10. SAND/GRAVEL PACK:
Material.,.
Bottom
Bottom
Bottom
Thickness/
Weight
o
Material
yethod 0aiontrf Ocki
le Ali'
Diameter Slot Size
Ft.
Ft.
Ft.
in.
in.
in.
Material
in. ..
in.
in.
. ,', ��z Depth Si; Material
Top .,,.� Bottcim - Ft. . a (L4t C
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
. / --t 0
---- t 0 / '---- f".3-J
•
/
/
/
/
12. REMARKS:
•
Formation Description
t If\:::)
MAR 201?
I DO HEREBY CERTIFY THAT THIS WELL
15A NCA912c,k/VELL,„C>liNURU TION
RECORp VAS
SIGfNAT
D
information Processing Unit
DWQ/BOG
,S CONSTRUCTED
ANDARDS, AND THAT
E WELL OWNER.
IN ACCORDANCE WITH
A COPY OF THIS
REOF RTIFIED WELL CONTIjACT
PRINTED NAM
OF PERSON CONSTR
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
F6k/Xact10-0.7 77'F-7?7?c?.
DATE
Form GW-1b
MAR 1 V'21i1