411604_Well Construction - GW1_20130211

TOPOGRAPHIC LAN TOPOGRAPHIC LAND SETTING: (check appropriate box)
❑ Slope [Walley VFlat ❑ Ridge ❑ Other
LATITUDE 38114 * ' Cliv " DMS OR 3X.XXXXXXXXX DD
LONGITUDE Ai 11 ° S;' (PS " DMS OR 7X.XXXXXXxxx DD
Latitude/longitude source: OGPS ❑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.)
c 4.� Z - . i. ntiv►er
,S130 P1/44-\i,e\*
Street Address
Cityor Tov
PA: VIC \-\0"3tWkike.._
Contact Name
c)0V=:00K
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 Dam], Inc.
Well Contractor Company Name
1006 Camp Creek Rd.
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# �fA
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) u ( I.
3. WELL USE (Check One Box) Monitoring tA Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation[ Other ❑ (list use)
DATE DRILLED to o t II 1 IS
4. WELL LOCATION:
S 11-0 tMo�r \LQ &lc -
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: U :1 �M�v1,��'�
COUNTY kW Loer
1 ` r h
aci{i ' ame �K� Facility ID# (if applicable)
411604
d. TOP OF CASING IS ..kr 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. METHOD OF TESTA/A.
f. DISINFECTION: Type /Uyi Amount Abi
g. WATER ZONES (depth):
Top/0 4 Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
. Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom P g Ft. . 5 Gil 40 Pia-
:
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
: Top C,3 Bottom ('4 Ft. ¢D r-k1Q ,4c1
/'Top (4 Bottom 110 Ft. R ti1 alePtrt"
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top ! ,olo
S Bottom 'a 3 Ft. a in. in. J2VG
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top 1 L Bottom 3 Ft.
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
0 I s
I in
a$uo‘ •
State Zip Code
orse-k‘ts ��.ca,��+�.y Cori!.
Mailing Address
Wit ;L Wo
City or Towrij State Zip Code
( to ) U 1Q o
Area code Phone number
6. WELL DETAILS:
1
a. TOTAL DEPTH:1
b. DOES WELL REPLACE EXISTING WELL? YES ❑ N?j
c. WATER LEVEL Below Top of Casing: iV ck FT.
(Use "+" if Above Top of Casing)
•
•
•
.
jo I IC
1' I a0
av / a.3
/
/
/
12. REMARKS:
Size a Material
?ONO �iJic,t
Formation Description
PtQwv ,c;1 ty 64.41
.
1rm 1 i14 �c
a'rey <( fly s 44.1
& cY_ ' i' )4y 5. a*.
&T ett 5 i }ll 5 a Ad
ti ,
•'iYLF'�
5 2fl13
-,....
N011e
I DO HEREBY -CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
. 15A NCA,'2C, W L CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO' ' 4 • ' BEE PROVIDED TO THE WELL OWNER.
v t` l81f3
IGATURE OFER'TfFIED 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,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09