413147_Well Construction - GW1_20130429

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AQUA WELL
PALL t7 t
NONRSIDENTIALWELJ. CONSTRUCTION RECORD
North Carolina Department of F,nvoonmcnt and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # � I
1. WELL CONTRACTOR:
Weil Contra or (Individual) Name
A 64, Loa LA)tti I A-q
Well Contractor - nw Name
/,..> b
Street Address
C.., ir
City or Town
(alt©)
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT*
OTHER ASSOCIATED PERMITInf appiic e)
SITE WELL ID Stir applicable)
3. WELL USE (Check One Box) Monitoring Cl Municipal/Public 0
IndustrlaVCommerc►ial Ci Agricultural 0 Recovery 0 Injection 0
IrrigationO Other p pet use)
DATE DRILLED Ii~/3
4. WELL LOCATION:
21- 0 itio
(met Name. Numbers, Community. Subdtvision. Lot No., Pam, Zip Code)
11/
•
State Zip Code
CITY: (A),144 COUNTY
TOPOGRAPHIC / LAND SETTING: (coed( expropriate box)
O Slope CI VVlley 5Fat cote Daher
LATITUDE ,°A' DMS OR 3x.xxxxXXXXX DD
LONGITUDE °je ' 41 DMS OR Zumwalt& DD
Latitude/longitude source: BPS QTopograpftic maP
(location of well must be shown on a USGS two map andettached to
this km if not using GPS)
6. FACILITY (Marne of the business where the well le located.)
Facility Name
Street Address
City or Town
Facility 100 (If applicable)
Stale Zip Code
Contact Name
MaMn6 Address
City of Town
State Zip Code
Area code Phone number
i. WELL DETAILS:
a. TOTAL DEPTH: 3r
b. DOES WELL REPLACE EXISTING WELL? YES p NO 01%.,
c. WATER LEVEL Below Top of Casing: )—
(Use `+' if Above Top of Casing)
rr.
Jr
41.3147
d. TOP OF CASING I9,IFT. Above Land Surface'
`Top of casing terrnknebed atlor below land surface may require
: a variance in accordance with 15A NCAC 2C .0118.
.
e. YIELD Wpm): � = METHOD OF TEST 'IA-
t. DISINFECTION: Type - - ._.. Amount
g. WATER ZONES (depth):
Top 8ottont Top Bottom
: Top _ Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Olsnister Weight Material
TOP BOttorn_241. Ft. Saikto et
TopBottom Ft,
TopBottom Ft,
8, GROUT: Depth Materiel Method
Top 6 Bolton a b . FI, 1'� C.f2c1A
TopBottomY Ft , .
Top._._.... BottomFL,
9. SCREEN: Depth Diameter Blot Site Medici
Top„ c 4 Boitont , , FLI rry In, C dd In, 4 c7-, •
ToP____.- Bottom`_____ Ft—Jn, __,___ In,
: Top Bottom_ Ft. In, in.
: 10. SANWGRAVEL PAC1:
Depth Site Material
Top BottomFt.
Top Bottoms Ft._,,,,,,,,,_
Top Bottom_ __ _ Ft.
11. DRILLING LOG
Top Bottom
Formation Description
�t
a 9P-41/4
/ Ir ,
/
/
/
12. REMARKS;
c_9.A.r., 5 S4
4111111110
NFORM ON. RE719G2613
00 HEREBY CERTIFY THAT THNe WU. WAS CONSTAUCTEO N AcOORO NCE Wrh4
15A PI:/.c 2C. WELL CONSTRUMICN STANDARDS, AND THAT A COPY OF THIS
SEEN • DED TO THE WEL/ OWNER.
R.
SIGNMr
UR
Asc-
C . TIRED WELL CONTRACIV
PRINTED NAME OF - RSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: bivision of Water Quality - information Processing,
1617 Mall Service Center, Raleigh, NC 27699.16 1, Phone : [phone]U0
RECEIVED 04-21-` 12 20:17 FROM- 9103133102 TO- I'IC DENS P&S
Form GW-lb
Rev. 2/09
PAA7/17112