412450_Well Construction - GW1_20130325

ON
ESI E TIAL WELL CONST .t UCH N REC
RD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRA.CTO CE '; TIF1CAT1tN # s� = /
14-
t.)
1. WELL CONTRACTOR:
Ronald Cannady
Well Contractor (Individual) Name
Cannady Brothers Well Drilling, Inc.
Well Contractor Company Name
1366 Bass Lake Road
Street Address
Roseboro
NC
City or Town State
910 ) 564-6207 / 910-564-4'
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
ca, s )1
28382
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial 0 Agricultural Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED / £ / a 12
41 2 ''-1 E'i 0
: d. TOP OF CASING IS / d Z --- 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 1' r r METHOD OF TEST 4 iii:
f. DISINFECTION: Type Hi 7 Al Amount .616-S.'-
: g. WATER ZONES (depth):
F.�'
: Top 5 6 Bottom ( Top / Bottom ) r�
Top Bottom ill (-/ Bottom
i Top 1a 0 Bottom / 2. .3 Bottom
Top is 1
Top / S
7. CASING: Depth Diameter
: Top r _ �a Bottom / Ft. °
Top Bottom Ft.
Top Bottom Ft.
: 8. GROUT: Depth
: Top .. Bottom ` ... Ft.
: Top Bottom Ft.
Top Bottom Ft.
Thickness/
Weigh
LS C /(3ii
4. WELL LOCATION: ; 9. SCREEN: Depth
" ' : Top 57Bottom / j$ Ft.
(Stree me Numbers Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY IJ"
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley grerat 0 Ridge 0 Other
LATITUDE 3 : `` ° A.: 9(e$ DMS 3X.XXXXXXXXX DD
LONGITUDE,? ° 6 S' Q r " DMS 7X.XXXXXXXXX DD
Latitude/longitude source: 15S ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.)
F-0-1-41,11
Facility Name
313....i
Street Address
City or Town
c'
Contact Name
S' C:..
Mailing Address
a
z
it)c.
S.�
Facility ID# (if applicable)
o1/4 k!QV
State Zip Code
e3c,'S"
City or Town State
9R)) ��--2.
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 8ISO ❑
4s, 'OT',vca • A� � "Y'J �'WlW3aq• � `
c. WATER LEVEL Below Topof Casing: 3 t FT. J{ ad, `�. ,uu t
(Use if Above Top of Casing) : PRINTED NAME OF PERSON CONSTR1 TIN .^ 1 L 1
. Y2013 ,,i
Submit within 30 days of completion to: Division of Water Quay - Information Processors ;.._.--- �_...__-_---__Form 09
I d'I 7 i1it•sat e.,,,,;". ?',.o..4,,.o. D.,,IaapatI tur, '97noci_i dti Dhi.o.oe . 1414 01 QQ17_t.' flf
Top
Top
Bottom Ft.
Bottom Ft.
/P5—
Material
(,/
Method
Diameter Slot Size Material
�in. 0 /5 in. �a
in. in.
in. in.
: 10. SAND/GRAVEL PACK:
. Depthize Material p
�g / 95-
�,`r a a t tee...
: Top Bottom Ft.°- -~�`
Top Bottom
: Top Bottom
: 11. DRILLING LOG
: Top Bottom
e.) „A
�. / (`)
9 /.
r / i/o
Ft.
Ft.
7
MAR 2 1 2O3
�t CT�N
MING INS -
ale /
12. l /d
,/ .Z s / *1. 4
/ 26 / • /; 0
12. REMARKS: 1 ..: 6
ater'. I
r '+
-4,
,e-ch
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECORD S BEEN PROVID TO THE WELL OWNER.
.14476
SIGNATURE OF CERTIFIED WELL C