GW1-2022-03763_Well Construction - GW1_20220404

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1!'ONRESMENTUL WELL CONSTRUCTION RECORD
North CarolinaDepartment ofEnvironment and Natural Resources-Division of Water Quality
`•Q,`•,®• WELL CONTRACTOR CERTIFICATION#NOW 4173 B
1.WELL.CONTRACTOR:' ;d.TOP OF CASING IS 3.5' Fr.Above Land SurfaceJoShtla CamnbelI Patterson 'Top of casing terminated at/orbelow land surface may require
We11 Contractor(Individual)Name a variance in accordance With 15A NCAC 2C.0118.
Patt cSo EXD)OTatlOfl S@NIC2S :e.YIELD(gpm):_f-10.10 METHOD OF TEST Ballet
Weii Contrector Comparry•Name r
P.O.°BOX 3008 :1. DISINFECTION:Type nOne Amount
Street Address
Sanford NC . 27331 90 WATER 30 BoHomep36 Top Bottom
CityorTovm State tip Code ;Tap Bottom Top Bottom
9f 19 l 774-3770 To Bottom Top I Bottom
Area code Phone number Thickness/
2.WELL INFORMATION: :7.CASING: Depth Diameter 1 Welght Material
WELL CONSTRUCTION PERMIT#NA :Top+3.5 BoftorrL 25 FL 2" lap PVC
OTHER ASSOCIATED PERMIT#(dappOcable)SR 0500027 Top Bottom FL
SITE WELL 10#(d applicablo)#4 Top Bottom FL
i 3.WELL USE(Check One Box)Monitoring tV.Municipal/Publicp ;8.GROUT: Depth Material f Method
Industrial/Commercal❑ Agricultural O Recovery[.injection❑ :Top 8.5 Bottom 24 FL 8entonite Tremie
irrigation Other[(Iistuse') :Top 0.0 Bottom 5 ,—FL Cement Tremie
DATE DRILLED 3-28-2022' ;Top Bottom FI.
4.WELL LOCATION; :9.SCREEN: Depth Diameter Slot Size. Material
3145 Rosser Road :Top 25 Bottom 35 FL 2 tn. .010 In. PVC
(Street Name,Numlrore,Community Subdii alon.Lot No.,Parcel,Zip Code) :Top Bottom - FL in. In.
CITY:Bear Creek couNTYChatham :Top Bottom FL m. in
TOPOGRAPHIC/LAND SETTING:(check appropriate box)
u(SIOpe[Valley OFIat ❑Ridge ❑Other. '10.SANDIGRAVELPACK.
LATITUDE 35 •34 57.am •DMS OR DD Depth Size J Material
LONGITUDE ^to B.a000 Top 24 Bottom 35 FL 16/40 Quartz Sand
_ •DMS OR :.:tjR; ::To
LatitudeAo elude source '.. P Bottom FL- �-o�
ng' WINS 13I'opographle reap :Top Bottom FL I.
00cafion of well must be shown on a USGS iopo map andaffached to
this form ifnot usirig GPS) :•:11.DRILLING LOG
S.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description J�i) 202,
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FarthtPaEnvironmental Inr SR 05000 7 0.0 12.0 Topsoil ''
Facility Name _ Facility ID#(if applicable) 2.0 /2.5 Orange Clay
31'4fi Rck oer Road 2.5 /33.0 Red Siltstofie and shale RVIA
StreetAddress1VA
RearC2riaek NQ 97907
City ar--town State Zip Code /
Inhnnu Ronn - /803 S77-S9471 /
Contact Name /
�3145'Roscar Rnad /
Maibng Address- / �
_Fear rIraak Nf 97 07 /
CdyorTown State Zip Code
C 9_1 q�774-1380 12 REMARKS:
(.
Area code Phone number
6.WELL DETAILS: :IDOHERESYCERTIFYT14ATC-HETWELLOWNER
SCONSTRUCTED,INACCORDANCEWRH
•I5IkNCAC2 WELL�yNDARDS,ANDTHA7ACOW OF THIS
a.TOTAL DEPTH:_351 casino ton -RECO BEENyftO
b.DOES WELL REPLACE EXISTING WELL? YES❑ NOEV
SIG TURE OF C RTIFlED WELL CONTRA T(S OR D TE
c.WATER_LEVEL Below Top of Casing:.7-6 FT.
- — (Use'+•ifAhoveTop of Casing) :PRINTED NAME OF PERSON CONSTRUCTING THE WELL
FarSubmit within 30 days of completion to:Division of Water Quality- information Processing, Rev.2109
1617 Mali Service Center,Raleigh,NC 27699-161,Phone:[phone] ev. 09
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