411608_Well Construction - GW1_20130211

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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 NC 28080
City or Town State Zip Code
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#.
OTHER ASSOCIATED PERMIT#(if applicable) O.
SITE WELL ID #(if applicable) p
3. WELL USE (Check One Box) Monitoring18 MunicipalPublic 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 11,4 0 i 1 / 1 2,013
4. WELL LOCATION:
St,() Y\ac \kG Sir
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: U;),,vni��t�r COUNTY (NCuJ 1"\w‘over
TOPOGRAPHIC LAND SETTING: (check appropriate box) TOPOGRAPHIC LAND SETTING: (check box)
❑ Slope [Valley gf Flat ❑ Ridge ❑ Other
LATITUDE 311 ° I a ' (11 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 17 ° Sc§' 4SC " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: [JGPS ❑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.)
V-D tf%Aork ** .60c WC)
Pacility Wame FacilityID#(if applicable)
Pp licable
)
•I3D MatticA
Street Address
ekVivqw41,N.ON
City or Town
(A: Ike_ c , e.VA .
Contact Name
1)0 tax 3aa7
Mailing Address
kyv\\ kOk
City or Town
JAL
State Zip Code
ocst\, Otertp.-A‘t,iNC6 CoeP
c 'kw) Lt`10 - i ssn
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: k
aSLI G
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOXI
c. WATER LEVEL Below Top of Casing: P f\ FT.
(Use "+" if Above Top of Casing)
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4183-A
411608
d. TOP OF CASING IS -19— 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): #J f t METHOD OF TEST A
Amount N�
f. DISINFECTION: Type Nik
g. WATER ZONES (depth):
Top tO kf Bottom
Top Bottom
Top Bottom
7. CASING: Depth Diameter
Top 0 Bottom 51 Ft.
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top Q Bottom 3 Ft. t? t tCA.J
Top Bottom
Top Bottom
Top Bottom
Thickness/
Weight Material
s l,uo pvc
Top 3 Bottom Ft. jevt1Qv ;
Top Bottom Ft.
9. SCREEN: Depth
Method
4our
Povr
Diameter Slot Size Material
Top 5 Bottom t 5 Ft. ja in. *0( d in. PVC
Top Bottom Ft.
Top Bottom Ft.
: 10. SAND/GRAVEL PACK:
Depth
Top {1 Bottom t s
in. in.
in. in.
Size
Ft. gol�o
▪ Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
•
0
12. REMARKS:
Material
sr1iti4
Formation Description
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Ott(y S thy 54.44
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PFR
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q Unit
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• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED j.N•A000RDANCE WITH
. 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND1tHAT A COPY OF THIS
: RECO t
S BEEN PROVIDED TO THE WELL OWNER.
.s.j.,
I NATURE F CERTIFIED WELL CONTRACTOR
▪ Michael Paul Brown
o < <3
D TE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09