413341_Well Construction - GW1_20130513

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION# coot -A.
1. TIACZTRACTOPps
owl
Well Contractor (Individual) Name
Cfl01),.gr i r. t't tf c ®-a,).
Well C6htractor Company Nam
tS(xi _a bit Art Qki,
Street Address ® S
•
City or Town
(&1SLo) $5 -1 )
Area code Phone number
2. WELL INFORMATION:
l ..J. &SDI 1Lo
State Zip Code
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT/Rs applicable)
SITE WELL ID #(rf applicable)ro. fl - As - e
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ° Agricultural 0 Recovery 0 Injection V
Irdgatlon0 Other 0 (list use)
DATE DRILLED 44 lc"- ( 3
4. WELL LOCATION:
eC1 comoGE4 1 ns e °.L9t `&-�^
Name, Numbers, Comfm� ', ubd'ndsion, Lot No., Parcel, Zip oCode)
CITY: .CP- u'W court -NI) w,loW
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope °Valley IWllat ❑Ridge ❑Ogler
LATITUDE 34 °�'FS®'i " DMS OR DD
LONGITUDE 77 adn' Q13 "DMS OR DD
Latttudefongitude source: giPS oropographic map
(location of well must be shown on a USGS topo map andattached to
this Pone If not using GPS)
5. FACILITY (Name of the businessinnwherethewell is located.)
(�t'..I elks+ flit Como C4 s'i/ v
Facility Name Fa ID# (if applicable)
nkt- PS•2�(0�1 (4. (ckkl < 8`tki c.
Street Address
Netts it-cchu()(t 1._0 'O�C. �tss�
City or Town State Zip Code
(Street
T (rn Mott LA.
Co�ame
i 4-17$ l tWks d "Z
Mailing Address
City uTdwnS F
MC. dscut3
State Zip Code
( Area code Phone(Sig nu®er9 lc
5. WELL DETAILS: c 'y
a. TOTAL DEPTH: D 8.
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO CT
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" ifAbove Top of Casing)
41334I
d. TOP OF CASING 15 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):
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 Weightw,f^it Material
5 Top_fL Bottom '7 Ft YV(� go N
Top Bottom Ft.
Top Bottom Ft.
8. GROUT:�..LDepth Material
LY Top Bottom 1C.S" Ft
Top Bottom Ft.
Top Bottom Ft.
Method
( resvia
9. SCREEN: Depth Diameter Slot Size
Topi9.1 •$Bottom RS Ft. 01, in. 0 rbzS in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Material
SS
10. SAND/GRAVEL PACK:
Depth Size Materiel)
Top g t Bottom KS ,it. . t cc�_'".'.'k,.,F/'1
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
CD) / (O
p / as
2n
_/ an
go/ s-o
S77 / coo
top ./ it
't0
g ®/ 8"9
12. REMARKS:
Formation Description
611 avt3 Q-1wjx si l+�
UmvAT ,r
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tas tnrl � .1\yint�
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a
riA 9i%elf Net L./
ATFN( LI/AE II
INFEN ATION f ROCESSIms UIVO
a4y.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS
RECORD tIAS BEEN PROVIDEgTO THE WEItF OWNER
SIGNATUR
PRINTED NAME OF PERSON CON
A-N
DATE
THE WELL
Submit within 30 days off completion to: Division of Water Quality - Information Processing,
1617 titan Service Center, Raleigh, NC 27699-161, Phone :'[phone]
Form GW-lb
Rev. 2/09