GW1-2022-03903_Well Construction - GW1_20220412

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ON ESIDENTIAL wELL CONSTRUCTION RECORD
- ; ✓ ' A North Carolina Department of Environment and Natural Resources-Division of Water Quality
�`•m�� WELL CONTRACTOR CERTIFICATION# NCWC 4173-B
1.WELL CONTRACTOR: d. TOP OF CASING IS 3.5 FT.Above Land Surface*
Joshua Campbell Patterson `Top of casing terminated at/or below land surface may require
Well Contractor(Individual)Name a variance in accordance with 15A NCAC 2C.0118.
Patterson Exploration Services :Well Contractor Company Name e. YIELD(gpm): (-)0.10 METHOD OF TEST Baller
P.O. BOX 3008 :f. DISINFECTION:Type none_ Amount
Street Address :g. WATER ZONES(depth):
Sanford NC 27331 :Top 30 Bottom 35 Top Bottom
City or Town State Zip Code ;Top Bottom Top Bottom
9( 19 ) 774-3770 Top Bottom Top Bottom
Area code Phone number Thickness/
2.WELL INFORMATION: ;7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#NA :Top +3.5 Bottom 25 Ft. 2" Sch40 PVC
OTHER ASSOCIATED PERMIT#(ifapplicable)SR 0500027 :Top Bottom Ft.
SITE WELL ID#(rf applicable)#4
Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring N(Municipal/Public❑ ' 8. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural❑ Recovery❑ Injection❑ :Top 8.5 Bottom 24 Ft. Bentonite Tremie
Irrigation❑ Other❑ (list use) Top 0.0 Bottom 5 Ft. Cement Tremie
DATE DRILLED 3-28-2022 :Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
3145 Rosser Road :Top 25 Bottom 35 Ft. 2 in. .010 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft. in. in.
CITY: Bear Creek COUNTY Chatham :Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
N(siope ❑Valley ❑Flat ❑Ridge ❑Other : 10.SAND/GRAVEL PACK:
LATITUDE 35 °34 •57.8000 - Depth Size Material
"DMS OR DD :Top 24 Bottom 35 Ft. 16/40 Quark Sand
LONGITUDE 79 14 • 6.6000 "DMS OR DD
— :Top Bottom Ft.
Latitude/longitude source: Q.'PS Ell-opographic map :Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) : 11. DRILLING LOG
5.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
Fartht c nyironm ntal In R 05000 7 0.0 12.0 To soil
Facility Name Facility ID#(if applicable) 2.0 / 2.5 Orange CIa1 ,
3145 Rosser Road 2.5 133.0 Red Siltst •
Street Address / ftfol
_ Bear Creek NG 27907 / oR '
City or Town State Zip Code /
Johnny Boone (80 -577-5 47)
Contact Name * f
3145 Rosser Road
Gi''.V•
Mailing Address /
Bear Creek NC 27907 /
City or Town State Zip Code : 12.REMARKS:
( 919 774-1380
Area code Phone number
6.WELL DETAILS: I DO HEREBY CERTIFY T THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15ALNdAC2C,WELL N T CTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 35' Casna toDBE P O 1 TO THE WELL OWNER. �
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b. DOES WELL REPLACE EXISTING WELL? YES❑ NO qI :SI ATURE OF CERTIFIED WELL CONTRACTO ±D—AVE—
c. R WATER LEVEL Below Top of Casing: 7.6 FT.
(Use"+"if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Form /09 b
y p ty- Information Processing, Rev.2/09
1617 Mail Service Center,Raleigh,NC 27699-161,Phone:[phone]