413148_Well Construction - GW1_20130429

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,71.44
AQUA WELL
PAGE 06
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1. WELL CONTRACTOR:
NONRESIDENTIAL WALL CONSTRUCTION RECORD
North Caroline Department of Environment and NaturalResources-Division of Water Quality
5)
WELL CONTRACTOR CERTIFICATION #
au
Well Con
ctor (Individual) Name
ti413
City or town
l916) s257./9 rt? _
Area code Phone number
t WELL INFORMATION:
WELL CONSTRUCTION PERMIT
Well Contractor Company Name
. « S• 6 %CQ
t Address
/4-2.
D9
State Zip Code
OTHER ASSOCIATED PERMIT#(it applicable),_.
SITE wELL 10 00 applicable)
3. WELL USE (Check One Box) Monitoring 0 MunicipallpubNC 0
Industrial/Commercial O Agricultural 0 Recovery 0 Injection O
(oation0 Other 0 PM use) ,
GATE DRILLED It —/ S -/
4. WELL LOCATION:
0_ ( $1
(Street Name, Numbers, Corrinunity, Subdivision, .. Per* 21p Code)
d. TOP OF CASING IS fr/
413148
F. Above Land Surface'
lop of casing terminated aVor below land surface may require
a variance in accordance with 1 SA NCAC 2C .0118,
e. YIELD (ppm): 3 o METHOD OF TEST
f. DISINFECTION: Typo Amount-
: 0. WATER ZONES (depth):
• :Top_ Bottom
Tip Bottom
Top Bottom
CITY: C.)Jr /M COUNTY,j4w#414.44).>e
RA
TOPOGPHIC / LAND SETTING: (check ammonite box) i
O Slope O Valley ORat O Ridge 0 Other,
LATITUDE L6' $ cr ( " DMS OR 3x-XxXXXXXXx 00
LONGITUDE 101`j1123 5 ' " DMS OR 7)0DU cx DD
LetitudeAongltude source: OGPS Oropogmphic map
(Location of well must be shown on a USGS t po map andattsched to
this lam if not using GPS)
6. FACILITY (Name of the business where the well Is located.)
Facility Name
Steel Address
City or Town
Contest Name
ANNIONIMI
Facility JD# (lf Applcable)
Stage Zip Code
Mailing Address
City Or Town
Arse Code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:, �D�
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES p NO
o_ WATER LEVEL Below Top of Casing: jot, FT.
(Use `*` tf Above Top of Casing)
•
♦ /
Top Bottom
Top Bottom
Top Bottom
: 7. CASING: Depth Diameter Weight Medal
Tor Bottom FL, S�.♦�, J Q..,.
Top Bottom_ Ft.
Top BottomFt._...—
8. GROUT: Depth
Top [� 8o0orL,, P
Top_ --_
T��------.— Bo ._
Material
o Ft. 'OA. 00(1A.,
FL
Ft.
Method
et) Gt
9. SCREEN: Depth Diameter Slot Size Material
Top,- 'a go a Ft. / f In. , WO In.
Top Bottom Fein, In,
Top__ bottom_ F't in ___ in-
10. SAND/GRAVEL PACK:
Depth
Top Bottom
Top Botom
Top 6ottom�—..., Ft.
: 11. DRILLING LOG
Top Bottom
•
/
12. REMARKS:
Ft.
Ft.
Size Material
Formation Description
.sfr
pr4fAili SE-1, I ION
iF wi ;�..rf 4{FtP`t! i'4 �7ir7 tO.JbF F,f!e7 `tit M V`
i Do HEREBY CERTIFY MAT THIS MtEU. V CONSTRICTED Its AC X/RON CE vt/Mi
. 1SIE NCAC 2C, WEE.!. CON sTRUCTtONt STAwfkRD5, MD TMe A COPY OF THIS
RECORD HAS KEEN PROII + YD THE WELt; oviNgR.
17/ '73.). P-13
SIGNA URE OF R 0 WELL CONTRACTOR DATE
•PRW4TED NAME OF CONSTRUCTING THE WELL
Submit within 30days of completion to: Division of Water Quality • Information Processing,
1817 Malt Service Center, Raleigh, NC 27699-161, Phone : [phone]
RECEIVED 04-21-' 12 214 : 17 FROM- 9102122102 TCl- 1 =NIP PRq
Form GW-lb
Rev. 2109
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