GW1-2021-00934_Well Construction - GW1_20210305

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality•>;` WELL CONTRACTOR CERTIFICATION# 3 3
1.WELL CONTRACTOR: ;d. TOP OF CASING IS LQ FT.Above Land Surface*
1--Cr1 1D M OLC-d 'Top of casing terminated al/or below land surface may require
Well Contractor(Individual)Name a variance in accordance with 15A NCAC 2C.0118.
P ZA Lielk-Dc'lt LY\a. It'1G :a. YIELD(gpm):_i. (O_METHOD OF TEST falY-
�IlControCforCompanyName ;f, DISINFECTION:TyP*—Ch QT\YIP. Amount 20 OZ
HLIZ R LLn ►Z',dtS ley
Street Address ;g. WATER ZONES(depth):
191O SxAkI,e, GA 3osm ;Top Bottom Top Bottom
City or Town State Zip Code ;Top Bottom Top Bottom
LIOLL) 7L45-ZIULP Top Bottom Top Bottom
Area code Phone number
Thickness/
2.WELL INFORMATION: 7. CASINO: Depth Diameter Weight Material
WELL CONSTRUCTION PERMrr'# :Top Bottom Ft. LO rr Ise 5� c-r-1
OTHER ASSOCIATED PERMIT#(s applicable) Top Bottom Ft.
SITE WELL ID Oil applicable) �Top Bottom Ft.
0.WELL USE(Check One Box)Monitoring❑ MuntelpaVPubllc9 S. GROUT: Depth Materiel Method
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ :Top Bottoms_Ft. +t c,-n
Inigstionp Other 0 (I et use) ;Top Bottom Ft.
DATE DRILLED 1 ;Tol Bottom Ft.
4.1W,ELL LOCATION: ;9. SCREEN: Depth Diameter Slot SW Material
ri t(�'ECIYI C ex -+� Ra :Top Bottom Ft._in. _ In.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft._in. _ in.
CITY: H0.yC5yillf, COUNTY_,,0.V :Top Bottom Ft._in. _ In.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
g(Slope pValley ❑Flat []Ridge ❑Other : 10.SANDIGRAVELPACK:
Depth SW motww
LATITUDE 36 "DMS OR 3x.xxmaxxxx DO ;Top Bottom Ft.
LONGITUDE 75 "DMS OR 7x.XXXXXXXXX DO :Top Bottom Ft.
Latitude/longltude source: C33PS Cropographic map :Top Bottom Ft.
lineation of well must be shown on a USGS topo map andatteched to
this form If not using GPS) : 11. DRILLING LOG
S.FACILITY(Name of the business where the well is located.) : Top Bottom Formation Description
fed uav
Facility Name Facility lDit(If applicabb) I I 5y , C-)(0.ve1 $•
A-e,
Street Address /
City or Town Stab Zip Code /
Contact Name
Mailing Address / �dAr; yral'ZP
I
City or Town State Zip Code .12 REMARKS:
U
Area code Phone number
S.WELL DETAILS: I W NE Y CERTIFY THAT THIB WELL WA6�NSTRUCTED IN ACCORDANCE WITH
'7 : 1aA N C WELL CONBTRUC nON al.
fARD AND THAT A COPY OF THIS
a. TOTAL DEPTH: HC-�' RAGOPWAU BEEN PROVI T LO iER.
b. DOES WELL REPLACE EXISTING WELL? YES❑ NQ9 :SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: q0 FT. �-•pt1 .J���Ae'(�
(Use'+•If Above Top of Casing) :PRINTED NAME OF PERSON CONSTRUCTING THE WELL
FormSubmit within 30 days of completion to: Division of Water Quality Information Procealn , Rev. /09
Y P tY - 9 Rev.2ro9
1617 Mail Service Center, Raleigh. NC 27699-161. Phone : [phone]