390193_Well Construction - GW1_20100101

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # L( O `7 �' Q
1 WE L ONTRACTOR�
Well C ntractor (Individual) Name
Well Contractor Company Name
69a$ V3IniQx5Y O# -(LS
Street Address
C k A A-5-6-05 A -
City or Town
(LW) 5/0- 0610
Area code Phone number
2-WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OE
3 I
d TOP OF CASING IS p` FT Above Land Surface*
`Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) N/ it METHOD OF TEST l'3/11
f DISINFECTION Type PM Amount
g WATER ZONES (depth)
-I- (� IQ 31 Y" Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) /i/ A
SITE WELL ID #(if applicable) A D Q
3 WELL USE (Check One Box) Monitonng 4, Municipal/Public ❑
Industnal/Commercial ❑ Agncultural ❑ Recovery 0 Injection ❑
Imgation❑ Other 0 (list use))/�
DATE DRILLED l a— 1 �C7-� CO
4 WELL LOCATION
p (to 6 ss 6
(Street Name, Numbers, Community, Subdivision Lot No Parcel Zip Code) /
CITY IZ-O fi C. COUNTY `aJl�i corn 7
TOPQGRAPHIC / LAND SETTING (check appropnate box)
❑Slope (alley ❑Flat ❑Ridge ❑Other
LATITUDE vs 35° as', I3"N " DMS OR 3x xxxxxxxxx DD
LONGITUDE 6 $a° 3a' 5 5` W "DMS OR 7x xxxxxxxXX DD
Latitude/longitude source PS pfopographic map
(locaton of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5i�FACILITY (Name of the business where the well is located )
/ ? G/t
/ Facility Name
a-0-0 f 3-00
Street Address
12®&Ai
Cityjor Town/� State Zip Code
I2t GUt A/l YJ 4o1cf01�
Facility ID# (if applicable)
cP-L D2)u-c
Contact Name
a 0-0/ 3-0-c,
Mailin Address
Pta-DC
City or Town
(gam) (O87 - 5a0�7
Q P L jo tJ
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 331
AJ c. a87o
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ Nqes
c WATER LEVEL Below Top of Casing 3?, 0 es FT
(Use "+" if Above Top of Casing)
7 CASING Depth
Top Bottom
Top Bottom
Top Bottom
Ft
Ft
Ft
8 GROUT Depth I,r
Top Bottom cW Ft
Top 04/ Bottom a 3 ' Ft
Top Bottom Ft
9 SCREEN Depth Diameter
Top �r. Bottom 3S Ft 19- ‘r in
Top Bottom Ft
Top Bottom Ft
Thickness/
Diameter Weight Material
Material Method
640 i 47 Erwr-er
eri & rl4 v t �f c
Slot Size Material
.6 lb in rVC_
in in
in in
10 SAND/GRAVEL PACK
i Depth
? Size
Top '� 3 ' Bottom 0 Ft * a -
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
/
tU' / as
/
-),'/ 3 `{--�-
12 REMARKS
Ft
Ft
Matenal
SAj N
Formation Descnption
Ur, tAL0' rQ crt 1ty r4N•-�
W ) c�jftAt/a� I S
►u.r--O. B n.o i.) i SrI fy fi t Nw
p 5a- I -fC �n+tia wi 9-Lt
R 19ntsk Sr1d-y 1.4s447
DEC 2 2 2010
WATE; C/L.,L, i Y ScC i f0N
I nrrl rrn-rar. �+ AJM� �?r� � �
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCErViTHIt
15A NCAC 2C WELL CONSTRl6CTION STANDARDS AND THAT A COPY OF THIS
REC RD HAS BE OVItE TO THE WELL OWNER
(a-r� /
SIG TURE OF CERUFIE/D WELL CONTRACTOR DATE
ea) /Q 6, C�6'/N/tgC
PRINTED 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