413337_Well Construction - GW1_20130513

1. WELL CONTRACTO /� g
tteU1eX) \ 9 O t rtht- -
Well� ontractor (Individual) Name
tin c CO
Well Co p r Comps y Slant
ISIe imp& e.Ir.
Street Address l.tti)¢SOrW
City or Town
( (55cs) 55d 1ct6
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT/Kt/applicable)
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # cake, -A
d. TOP OF CASING 1S VIS 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 (gem)' 1 t ‘ METHOD OF TEST pomp
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(, Ft. ors r5 4 rnnt,
Top Bottom Ft.
Top Bottom Ft.
At.
State
3584°9
Zip Code
SITE WELL ID #(f applicable)Z& itC1 N w va
3. WELL USE (Check One Box) Monitoring tMunicipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection °
Irrigation° Other 0 dist use)
DATE DRILLED Li- 7-13
4. WELL LOCATION:
da{¢n
(Street Name, um omm Hy, Subdivision, tot N arose), Zip Code)
CITY: cot-CIOA V.`d is COUNTY l Ws(otN1
o., P
TOPOGRAPHIC / LAND��iSETTING: (check appropriate box)
CI Slope °Valley Idlat ❑Ridge ❑Other
LATITUDE 34 °tti 3 ' $'S'R " DMS2 BR
LONGITUDEn °. o' 941- "DMSOR
DD
DD
Latitude/longitude source: [EPS °Topographic map
(location of well must be shown on a USGS topo map andattached to
this fonn ffnot using GPS)
5. FACILITY (Name of the business where the well is located.)
41c ( Fhs,R- -one 6 /Riyt�i C t(' r
Facility Name (facility ID# (if applicable)
LAljrr5i /g4 Off. (# eta t ¢
Street Address
Jncrfitw/L d 5C/n
Zip Code
i
City or Town State
tr /Mr lit are
Co ct Name
>c7r7
Mailing Address (L
M Ale &5
City or own own State Zip Code
(Q'!n) Zara 4" tict I ®Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: r4O
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (�
c. WATER LEVEL Below Top of Casing: FT.
(Use "+° if Above Top of Casing)
413337
8. GROUT: Depth Material Method
Top th Bottom 11 fi Ft. rteN1< i v+
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top I.i" Bottoms
Top
Top
Bottom
Bottom
Diameter Slot Size
Ft 4 in. .CAL) in.
in.
Ft in.
Material
Ft. in. in.
10. SANDIGRAVEL PACK:
Depth Size
Top I. Bottom GO Ft. S- (
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
IS'
alb
92. REMARKS:
MM5a�-t,e�.ri^aal s
Formation Description
iNFp��
AFER�IQQL/G(PALITYCtCCESSItUC.(INIi SECTION
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF THIS
RECORD BEEN PROVID TO THE ';OWNER.
RE OF CERTIFIEDnW CONTRA Ti R DATE
/
✓N i'- GOO�A t0
P PC1NTED NAME
AME OF PERSON CONSTR CTING THE WELL
Submit within 30 days of completion to: Division off Water Quality - Information Processing,'.
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09