390192_Well Construction - GW1_20100101

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # - O 7 - 13
1 WELL C NTRACTO ( 1
biNC-u!,3 G-t C / N a t C.v�
Well Contractor (Individual) Name
Sy-'4 /%1 l k.1
NS
Well Contractor Company Name
toN")7 04-/XS JC
treet Address
City or Town
(42-3) S/ O C I(6
Area code Phone number
T,S 37L//(o
State Zip Code
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# /Q/ /41
OTHER ASSOCIATED PERMIT#(if applicable) t J�,4
SITE WELL ID #(if applicable) A 11'' 4f'
3. WELL USE (Check One Box) MonitonngottMunicipal/Public ❑
Industnal/Commercial ❑ Agncultural ❑ Recovery ❑ Injection ❑
Imgation❑ Other El (list use)
DATE DRILLED 1 a - S- iO
4 WELL LOCATION
1) RO ( IUE. 'S ct y
(Street Name Numbers, Community, Subdivision Lot No Plat6ei Zip Code)
CITY *2 Q �I J N Cq�- COUNTY COWLC•C
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope Valley ❑ Flat ❑ Ridge 0 Other
LATITUDE 30 35 "a8' (CrA/ " DMS OR 3x xxxxxxxxx DD
LONGITUDE 8 VA. Cry " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source *PS pfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 FACILITY (Name of the business where the well is located )
Facile Name Facility ID# (if applicable)
(1-Q,6 f C P t)-- L D- Tu Ot
Street ddress
A 2 E-jv (•-) C-,
City or Town State
1 CIA. ,VL O L k A1-O l3
Contact Na e
0 0-0 3 0t) C P eI L O R d Or
Mailing A dress
9.8?0e(
Zip Code
AI -U &"-i , e, e704(
City or Town State Zip Code
( $9_$) (87— %
Area code Phone number
6 WELL DETAILS J ,
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WE - LLL' YES ❑ NO
-A
WATER LEVEL Below Top of Casing alai 1365 FT
(Use "+" if Above Top of Casing)
3 O192
,rn
d TOP OF CASING IS 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) AY /4- METHOD OF TEST ICY ii
f DISINFECTION Type t) //53 Amount
g WATER ZONES (depth) /
Top 4 e Bottom 3 5 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth , Material Method
Top O Bottom a2S Ft 4� Mai Oct T`t 10f) t"
Top ,S i Bottom a Ft 1Er63 N,) - trC 5 401 v f"t y
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
a
Top 30 / Bottom 3S Ft a '( in , Ol'b in ('' V C-
Top Bottom Ft in in
Top Bottom Ft in
In
10 SAND/GRAVEL PACK
C f Depth Size M tenal
Top t d Bottom 3S Ft off- N
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
6 I 33'
3/ 3 s' c'17 j S.7,440)/ e /4y
/
12 REMARKS
Formation Description
CoA / �sG,
DEC 2 2 2010
Inforn' aon Fr:;,es .trt(i Unit
I DO HEREB'j CERTIFY THAT THIS WELL AS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2Q WELL CONSTRUCTION ST NDARDS AND THAT A COPY OF THIS
RECORD HAB BEEN PROVID TO THE LL OWNER
SIG TUF OF CERTIFIED W CONTRACTOR DATE
/ +J CJ COO O ft C/`-
PRI TED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-lb
Rev 2/09