413143_Well Construction - GW1_20130429

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1. WELL CONTRA T R:
ON ESMEN, nAL WELL CONSTRUCTION RECORD
Now Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
d. TOP OF CASING 18 FT. Above Land Surface'
'Top of casing terminated aVor below land surface may require
• a variance in accordance with 15A NCAC 2C .0118.
s. YIELD (Apni) METHOD OF TEST
;1. DISINFECTION: Typo Amount
g. WATER ZONES (depth);
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
•
Thickness/
7, CASING: Depth Diamoler Weight
Top ''`' Bottom ? o Ft, it S e Y 0
Top BottomFt.
Top ..__.. Bo FL
S
or (Individual) Name
i►.
well Contrecbx Company Name
_i_•Itt.k2___Actt..tiv '
StrBAt Address
CO • _ _ •
-=7
. IP4O
City or Town State Zip Code
9/0) .5 / 1/1_
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT
OTHER ASSOCIATED PERMITlt(ir epOicade)
SITE WELL ID 400f� L ..r.._..._
3. WELL USE (Cliff One Bow) Monitoring O Municipal/Public 0
Industrial/Commercial 0 46 tura, O Recovery O Injection 0
Irrigedon Other 0 (list uses ..-
DATE DRILLED, 5 .1 a 13
4. WELL LOCATION:
'?13143
Material
e 41.‘
8. GROUT; Depth Material Method
Top 0 Bottom 'v_,. FL #dtf1u - U L., r
Top Bottom FL_„. _ - Top Bottom Ft
8. SCREEN: Depth Diameter Slot She
�® e B Tapes Bottom e ' Ft.
9 to , Community, , Lot No•, Parcel, Tp Code)
CITY: �,,� t •''� , COUNTY ,U+ ) R4M.),I4(
71(,)CXXXXXax OD
TOPOGRAPHIC / LAND SETTING: (check aporopriete box)
os� ovaus� ��t aaaoo Daher
LATITUDE rite uG� s'6 � ores oR
.ONGITUOE �•}�' OS'S._ " OAAS OR
Latitude/longitude source:
(location of wbll must be
this form if not using GPS)
6. FACM.ITY (Name of the business where the well is located.)
3x xxxxxxx0oc 00
PS OTopographic map
on a USGS topo map andattached to
F Ny Name
Facility IDS (if applicable)
Street Address
City or Town
Contact Name
Meiling Address
City of TOswn
State Zip Code
She Zip Code
Are* code Phone nuns
6. WELL DETAILS:
/
a. TOTAL DEPTH: .7 ® . . -
b. DOES WEU. REPLACE EXISTING WELL? YES p NON,.
c. WATER LEVEL Below Top of Casing: 14 FT.
(Use '+' If -Above Top of Casing)
MetsrIa1
0/Din,,--
Top BottomFt In.
Tog,..,,.,,,_,.,_,_ Bottom Ft'_,_„__ in• In.
:10. SAND/GRAVEL PAC*:
Depth Size Material
: Top Bottom FL.
Top _ Bottom Ft
Top BottomFt
: 11. DRILLING LOG
Top Bottom
Formation Description
, a 0
• . 00• / ' _... cog, s'1
/
1
/ •
12. REMARKS:
cio HEREBY curnn• not rta WELL WAS coternucreo IN Acc Romeo WITH
• is', NCAC 2C• WELL GONST - • STANOMr, S, AND T14 T A COPY OF THIS
RE' . - ' P As BEEN Itif 1NEi; OvoieR.
fifr‘”.'/F
SI t .. TUFF • OF 'IED WELL CON'1'RACf©R DATE
rPRINTE04 OF PERSON DUCTING THE WELL
Submit within 30 days of completion to: L)ivision of Water Quality - information processing,
1817 Mali Service Center, Raleigh, NC 27699.181, Phone : /9191 807.63u0
Rpri:Tvp'n GIa-?1-' I 7L 17 FROM- 9103133102 TO- NC DENR P&S
Forth GVv-1b
Rev, 2f08
P011/012