411609_Well Construction - GW1_20130211

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4183-A
1. WELL CONTRACTOR:
Michael Paul Brown
Well Contractor (Individual) Name
Mad Dawa, Inc.
Well Contractor Company Name
1006 Camp Creek Rd.
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# }IV`v°t : Top l3 Bottom Ft. -- ScI%g1 ,I'C
NC 28080
State Zip Code
411609
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 (gpm): # r4 METHOD OF TEST Alt
f. DISINFECTION: Type AM Amount /
Bottom
Bottom
Bottom
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(if applicable) F P 1 IZ
3. WELL USE (Check One Box) Monitoring Ni Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 01 I III 2013
4. WELL LOCATION:
5CIO /Jttxcts,tt S
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Li; i dv. -0rt\_ COUNTY OW) t4ovvver
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Walley (Flat ❑Ridge DOther
LATITUDE 311 ° ! LI ' Cc'1 `Z " DMS OR 3x.xxxxxxxxx DD
LONGITUDE 7,6 77° $"a ' v�� "DMS OR 7X.xxXXXXXXx DD
Latitude/longitude source: MPS ❑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.)
r' $, sr-- Q'dt3 « arr
�(Varilier)
radii ame
��� Facility ID# (if applicable)
SRO Moke ,e-k S
Street Address
Am\wA-61..
City or Tow
State Zip Code
M;VIt \\G...Atk'oAK, \Ahrst\v60 [Ofp
Contact Name
C;)
Mailing Address
' t\ t \t OC 44140
City or Town State Zip Code
( C MO ) Lt10
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: IC
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV
c. WATER LEVEL Below Top of Casing: d ,Pc FT.
(Use "+" if Above Top of Casing)
: g. WATER ZONES (depth):
Top l o ‘,/ Bottom Top
Top Bottom Top
Top Bottom Top
Top
Top
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 3 Ft. Porflo.".elov
Top 3 Bottom 4 Ft. (?ev4on.'4e-
Top Bottom Ft.
9. SCREEN: Depth
Top- Bottom
Bottom
Diameter Slot Size Material
15 Ft. a in. .v !v in. Pve
Ft. in. in.
Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top q Bottom
Top Bottom
: Top Bottom
: 11. DRILLING LOG
Top Bottom
•
•
.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
ID
I iS
Size Material
I.c Ft. 0i0%0 't,i ci4
Ft.
Ft.
Formation Description
/ &Ow& ‘,' 14
l
/ v Arrow Ali' 1 +y S� .
&f(y �v'$fii
12. REMARKS:
Noce
•
5}0.13-
Iforrnat ot-rDrocess€nq Unit
h � Q/€BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, W CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
. RECORD HA :. ' ROVIDED TO THE WELL OWNER.
01/ /13
SIGE OF CERTIFIED WELL CONTRACTOR DATE
Michael Paul Brown
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
919
c i
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] g
Form GW-1 b
Rev. 2/09