413355_Well Construction - GW1_20130513

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4(r 9OR — A
1. WEL CONTRACT R:
Well Contractor (Individual) Name
M otese�tt(‘'' CO•
Wel ontractor Compa Name
t5,p Q, vanr)f>l- Cst-
Street Address
avftokil. o co 2 i
City or Town State Zip Code
(OSO) � '7C�
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#Qf applicable)
SITE WELL ID #(if applicable)Zt 5k acc^
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0 Industrial/Commercial 0 - Agricultural 0 Recovery 0 Injection E/
Inigation0 Other 0 (list use)
GATE DRILLED 41 'a-(- 13
4. WELL LOCATION: p
5 fAss So( ( p ciEre a akorsettsu n trivAr gl;
(Street Name,lNumbers, Comamuaity, S 66division, Lot No., Parcel, Zip Cade)
CITY: C. SLC. 6r.4kit( A) COUNTY OMsIBCL)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope 0Valley ❑Flat 0 Ridge ❑Other
LATITUDE 34 °4.13 "DMS OR DD
LONGITUDE77 °oip'�q-g' DIVISOR DD
Latitude/iongitude source: IC PS pfopographic 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.)
ry)c F sl. MCA Oot)Ap Cre.cct
Facility Name __Faal D# d applicable)
ntl'2V5.ee6'r915 [nr-cc'� (9 ^ R1:inA
Street Address r nc lcsap;lt(i 0 • t8$ `y
/6
City or Town State Zip Code
To jv r MctiN
Name
t '?8" 7
M ding AddreJRs^
�'�Q1h Ind Ua S AJC Ii€ I
City or to Zip Code
(11i) ea4`d -dg1 C
Area code Phone number
6. WELL DETAILS: a. TOTAL DEPTH: D o-
i
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 67
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
A n05i
d. TOP OF CASING 1S tU FT. Above Land Surface"
"Top of casing termina}ed at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
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
7� Material
Top �
Bottom tS Ft. (' & (/c
Top Bottom Ft.
Top Bottom Ft.
8. GROUT:"T�Depth Material Method
Top 45 Bottom 7Lr Ft. CBtsub{ (g • TTtua 0 0
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Topg9.5"-Bottom krFt. 9 in. qt''o in. 53
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SANDIGRAVEL PACK:
Depth Size Material A
Top gBottom6'5•CR.-#1 5(j i
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
4 / 10
Lo/rae
/ ST)
12. REMARKS:
Formation Description
rsA
MAY `3` !I9
MAY u 2013 ' .a
WAFER QUALITY 4- `CTION
!@FORMATION PROC ;,SING UICIT
I00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C W ELL CONSTR,IFTION STANDpttDS, AND THAT A COPY OF THIS
RECOR. •BEEN PROMO D O THE
C (Pi
SIGNATU•�0F:CERTIF D WaCCONTRAC
t 1.1
41116.
J S
R DATE
c� L
PRIME NAM OF PERSON CONSTRUCTIN e,'THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 90ai1 Service Center, Raleigh, NC 27699-161, Phone :; [phone]
Form GW-lb
Rev. 2/09