403634_Well Construction - GW1_20120319

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ^;
1. WELL CON ACTOR
l''''''') Y(?
Cam)Lell,�ontractor,(I diir, du 1) ame E,a
,\GL-, 1 i i i I i if j
r . l I rontractor Company Na e
L H 1 I.
r
Street Addr ss, .4 4V(._
HCIA 0/1 'S-',/- e e„
City or Town, -
.) F
�' -r' (,, (1,,,,
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ t»h0 (ILst use)
DATE DRILLED c "lird,
-
4. WELL LO TI€JPJC
Ir
(Street Na e, \lumbers, Community, Subdivision, Lot No., Parcel, Zip Code) •
CITY: L ( f V %(5\OQ COUNTY t/C � :IA% F
TOPOGRAPHIC / LANDE•TTING: (check appropriate box)
❑Slope ❑Valley q'f lat 0Ridge ❑Other
LATITUDE 36 a '
" DMS OR 3x.xxxxxxxxx DD
LONGITUDE 75 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: ❑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 State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
(
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
: 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.
e. YIELD (g p m) : t,, 4 �. TEST f Li
'a .. s.
: f. DISINFECTION: Type Amount
: g. WATER ZONES (dept
Top Bottom y- r Top Bottom
: Top 114 Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
.
7. CASING: Depth Diameter Weight . M terial
Top Bottom` Ft. � '`" • 12r,
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
fnlitifift C...., --
To ' Bottorn`'� Ft. fl*\i4,
: Top"".._ I?.' Bottom- Ft. 0 - L' 9+ 1('tt4
Top Bottom Ft.
9. SCREEN: Depth • ' - Diameter Slot Size Material
: Top- Bottom"` 1,. . Ft. in. \O in.
: Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
i 9k\ / '''. 1 0
12. REMARKS
•
ear
.Form. ion Descripti n
CA t
ethod
.M
•
C
CI n
i ty =- sOrriC rOkletj`
)( C r
1-10
AR
itiontattrati -
ug
k •
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WE CO, ..TRUCTON STANDARDS, AND THAT A COPY-OF•THIS
• RECORD HAS BEEN Pt ID 0 TH. DOWNER
,r, ,/
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO '' SIGNATURE OF C RTIFT D ��' L CONTRACTOR
,./y
c. WATER LEVEL Below Top of Casing: r FT. C ;' r
(Use "+" if Above Top of Casing) �.
PRINTEI NAME OF PERSON CONSTRO
Submit within 30 days of completion to: Division of. Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Fa-V41 34 ilia 7?-7q
s
DATE