385347_Well Construction - GW1_20100712

HIolIS6o
NON ONRESIDENTIAL WELL CONSTRUCTION RECORD
?erg Carolina Department of Environment and Natural Resou_ces-Dress on of Water Quality
WELL CONTRACT OR CERTIFICATION # Z. I Ct
1 WELL CONTRACTOR
KC
Well Contractor (Individual) Name
M°.0 (oi ► p� ��,�\4 ° ,
Well Contractor Company Name
STREET ADDRESS G-10Q`
C�fle toter iJ.0
City or Town State
(10'1 )- 3rt1 • ! SOL
Area code- Phone number
2. WELL INFORMATION.
SITE WELL ID #(if applicable}
Zip Code
STATE WELL PERMIT#(dapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitonng 0 Municipal/Public ❑
Industnal/Commercial 0 Agncultural 0 Recovery ❑ Injection 0
Irngation❑ Other 0 (list use)
DATE DRILLED S 10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION.
CITY-k-s+ COUNTY-1+�
Sri °9 kkk\\ 96. ,
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑Flat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3
LONGITUDE
May be m degrees,
minutes, seconds or
in a decimal fomiat
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. FACILITY. Is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY NSF
1
STREET ADDRESS .5 ,
City or Town State
CONTACT PERSON OA .�
MAILING ADDRESS
Zip Code
City or Town
State Zip Code
Area code - Phone number
6. WELL DETAILS:
a TOTAL DEPTH
b. DOES WELL REPLACE EXISTING WELL? YES 0 NOI
c. WATER LEVEL Below Top of Casing C) FT
(Use "+' if Above Top of Casing)
41; , t" 6t
t� G" _
d. TOP OF CASING IS Z III_ 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) 0 METHOD OF TEST 0
f DISINFECTION. Type 0 Amount 0
g. WATER ZONES (depth)
From To From To
From To From To
From To From To oC.\
6. CASING. Thickness/
Depth Diameter Weight Matenal
From O To —7 Ft 1 X.I.3O P. C
From To Ft
From Td Ft
7. GROUT Depth
Matenal
From 0 To -3 Ft Pe(\nQ
From To Ft
From To Ft
8 SCREEN Depth Diameter
From —1 To —2-7 Ft t In
From To Ft, in,
From To Ft in
9. SAND/GRAVEL PACK:
Depth Size
From S To 2.7 Ft V- 3
From To Ft.
From To Ft
Method
Slot Size Material
4tt0 In
In,
in
PvC
Material
St1tr;,
10. DRILLING LOG
From To
C� 2:7 1
11. REMARKS,
` -S
Formation Descnption
T' • IC r ..�
JUI_ 1 2 1 nM
informati0n
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PR I TO THE WELL OWNER
31.10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-lb
Rev 7/05