385351_Well Construction - GW1_20100712

IVON EaSI� IVT'�9L WELL CONSTRUCTION RECORD
'loth Carolina Department of Environment and Natural Resources-Dtv's,or of Water QuaLh,
WELL CONTRACT OR. CERTIFICATION #
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1 WELL CONTRACTOR
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Well Contractor (Individual) Name
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Well Contractor Company Name
STREET ADDRESS G-1 C7Q
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City or Town State
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Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) — G S
STATE WELL PERMIT#(dapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitonng ❑ Municipal/Public 0
Industnal/Commercial ❑ Agnculturai 0 Recovery 0 Injection ❑
Irngation❑ Other ❑ (list use)
DATE DRILLED lc)
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION. -�
CITY COUNTY 13,e.
"Sr, i $ \.•ill Q ,
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING
❑Slope ❑Valley ❑Flat ❑Ridge C] Other
(check appropnete box)
LATITUDE 3
LONGITUDE
May be m degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source. ❑GPS ❑Topographic map
(Iocatton of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY- Is the name of the business where the well is located
FACILITY ID s(if applicable)
NAME OF FACILITY NSF t a 9-ui-4n,L..1 ,n.,.,?)L11,
STREET ADDRESS S op.„ \-1,4 Q,.& ,
City or Town State
CONTACT PERSON---Neg_iL 3e9o,,..—.
MAILING ADDRESS
Zip Code
City or Town State
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO.
c. WATER LEVEL Below Top of Casing 6 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 2-t'2 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 L
f. DISINFECTION Type V Amount 0
g. WATER ZONES (depth)
From To From
From To From
From To From To
6. CASING.
Depth Diameter
From 0 To 3 Ft
From To Ft
From To Ft
7. GROUT. Depth
or)
Thickness/
Weight Matenal
5<l.10 Pvc
Matenal Method
From 0 To t Ft ro.o
From To Ft
From To Ft
B. SCREEN Depth Diameter Slot Size Material
From 3 To I. Ft 1 in in Pv'<
From To Ft in in.
From To Ft in in
9. SAND/GRAVEL PACK:
Depth Size Matenal
From 1 To l Ft l� 3 S t 1, C.o
From To Ft
From To Ft
10. DRILLING LOG
From To
11. REMARKS:
formation Descnption
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Pal e.�c�u. . • 2
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WfTH
15A NCAC 2C WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HA BEEN PR TO THE WELL OWNER
,•31.10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
t N, a. +,- M�Q�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-lb
Rev 7/05