413331_Well Construction - GW1_20130513

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION n
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CONTRACTr 1Q
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WIontrActor Company e ^ ` f .
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City or Town State Zip Code
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Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID ft(if applicable) t Q- k4 55 1(a.)
3. WELL USE (Check One Box) Monitoring IMunicipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
IriigationlJ Other ❑ (list use)
DATE DRILLED '1"1(D•. 13
4. WELL LOCATION:
644 RO (berN �; Pr ire/ scar t-ipti t�4. 65 €
(Street Name, Num , Com Ity,.Subdivision, Lot a., Parcel, Zip Code)
CITY: s‘o.ttsnouuttUi cowry pars&ntf3
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope JValley D Flat ❑Ridge ❑Other
LATITUDE 34 °,43' &S4 °DMSOR DD
LONGITUDE77 °a(0'��Q��'Y16 "DMS OR OD
Latitude/longitude source: adrilP' S ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this-fomr if not using GPS)
S. FACILITY (Name of the business where the well is located.)
MC I F. ,-t. @sp. G-; e r
Facility Name Fap{lityI (d applicable)
jaaeetAddress
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City or Town State Zip Code
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M icing Ad Gress
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City or'fTown - State Zip Code
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Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: (-t®
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Cg'
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING 15 9 . ,S 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): i. • S-- METHOD OF TEST pump•
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth �f Dlameter Weight �fM-/aa^larial
Top 4 Bottom 40 Ft a Stiff t40 PY
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 4 Bottom u7Q
Top Bottom
Top Bottom
Material Method
Ft. (tat* l ilvaIIt&). t
Ft.
Ft
9. SCREEN: Depth Diameter Slot Slze Materiel
Top 35— Botlom UCH Ft a in. orstD in. 1VC.
Top Bottom- Ft. in. _ in.
Top Bottom Ft. in. in.
10. SANDIGRAVEL PACK:
Depth Size
Top 33 Bottom 40 Ft. 1&
Top Bottom Ft.
MaterialccialAt
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
S l 1®
In /
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12. REMARKS:
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Formation Description
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MAY 3 2013
YVAI I- ,QUA SECTION
INFORMATION P ESSING UNIT
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PR ED TO T E WELL
WNER.
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SIGNATURE OF CERTIFIE • ELL CON CTOR DATE
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PRINTED NAME OF PERSON CONSTRI1ikTING THE WELL
Submit within 30 days of completion to: Division of Water Duality - Information Processing,
1617 Mail Service Center, Raleigh, NO 27699-161, Phone : [phone]
Fonn GW-1 b
Rev. 2/09