413335_Well Construction - GW1_20130513

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # Lao 8
1. WE 44 CONTRACT
{1t hou . Ultti
Well Contractor (Individual) Name
M( ar 'r; U u
Well Gilantractor Company Sante
iSir e3 !rrp rF CA('
Street dres{,
1-tUN t)tW
City or Town
( SLA) iiS'a- IOM
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#iif applicable)
SITE WELL ID #(if applicable) t tL-&Cl tt1AN - t a-LO
3. WELL USE (Check One Box) Monitoring CW"MunicipalPublic ❑
IndustriallCommercial ❑ Agricultural ° Recovery ° Injection 0
Irrigation° Other 0 (fist use)
DATE DRILLED Li-I$'4.3
4. WELL LOCATION: A
`r'liis tQ Qxiuyp &'r/1 Ottc3Ptx;EXsl afn ty' C s= St
(Street Name, Num rs, C mundy, Subdivision, Lot No., Parcel, Zip Code)
art: '3 CS a.,v; be.
AL 3S-Oto
State Zip Code
COUNTY Of-KtDCA.)
TOPOGRAPHIC 1 LAND�SETTING: (check appropriate box)
❑Slope °Valley Q#at ❑Ridge ❑Other
LATITUDE 34 ° 43 S(Lt "DMS OR DD
LONGITUDE 77 °,I`I ', -P�1F,!0A " DMS OR DD
t,_ Latitudeilongitude source: PS propographic map
(location of well must be shown on a USGS topo map andatiached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Mc.1 FAS.(. Mr.0 /ewmo Gap pr
„read( Fa I ID# (if applicable)
Address
ksem tit NC. a8rdp
City or Town State Zip Code
�e< felt MaDer 4-
�
Name
Facility Name
Conte
r'-t-�R-( t-o-LUI4
M�dirlg Address
City or
thteeld
wn
(410) Coot -(4R'S'
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: Cto
MC; sgL1g3
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES V NO °
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
413335
d. TOP OF CASING IS rd • S FT. Above Land Surface
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): t METHOD OF TEST p
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top ¥ Bottom 440 Ft e2 'irk 40 QVt
Top Bottom Ft.
Top Bottom Ft.
th►Al°D-
8. GROUT: Depth Material n Method
Top et> Bottom 3 k Ft. Cit L sy5nw,i a9.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top is' Bottom LIO Ft. 4 in. ° OW In. MR —
Top Bottom Ft. in. in.
Top - Bottom Ft in. In.
10. SANDIGRAVEL PACK:
Depth Size Mater a
Top �3 Bottom 440 Ft $t-t r
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
p Formation Description 0
tent ,
o/ tD
tf1/ it—
' Y/ AO
at / at
.sl SO
3 t/
/
/
/
12. REMARKS:
wPOSIErsaa
affirIPM h.
•
MAYWATIaw ITY
INFORMATION ('ROC
TION
.,ING UNIT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTS IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION SrDARDS, AND THAT A COPY OF THIS
RECORD - BEEN PRO - 'TOT ELLO- ER.
SIGNATURE OF CERTIFIE - ELL CON
-._JLv E u 3
R DATE
PRINTED NAME OF PERSON CONSTRUCTIN �'\, THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1b
Rev. 2109