381087_Well Construction - GW1_20100215

1 WELL CONTRACTOR
Joe Fornecker
7Q33 597
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3505
d TOP OF CASING IS I 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) 60 METHOD OF TEST ON
Well Contractor (Individual) Name
McCall Brothers Inc,
Well Contractor Company Name
6700 Brookshire Blvd
Street Address
Charlotte
City or Town
( 704 ) 399-1506
State NC Zip Code
Area code Phone number
2 WELL INFORMATION /'n
WELL CONSTRUCTION PERMIT# LIO ICCG) —1
/Vd
OTHER ASSOCIATED PERMIT#(ifnappliable)
SITE WELL ID #(if applicable) iv fA
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/
Commercial E Agricultural E Recovery E Injection E
Irrigation Other ❑ (list use)
DATE DRILLED i ZitQ
4 ELL LOCATION
Voile's(Ln. E2270
(Str et Name, Numberrs, Community, ubdivision, Lot No , Parcel, Zip Code)
CITY C I COUNTY / arc1c k
TOPOGRAPHIC / LAND SETTING
❑Slope EValley Flat ❑Rid e
LATITUDE 29 3S° O4' 444 I]
LONGITUDE OHO ° Ll6' Q 1.4Z
(check appropriate box)
❑ Other
" DMS OR 3x XXXXXXXXX DD
" DMS OR 7x XXXXXXXXX DD
Latitude/longitude source UGPS fltopographic 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 )
Facility Name
Street Address
Gty� Tos n
(f/ C
Contact Name
° C7 LJc04 V Ilei /ten
Mailing Address
G1 la R
City or —own
5177
A a code Phone number
6 WELL DETAILS'
a TOTAL DEPTH.
?Ct
State
Zip Code
NC 2J3
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES E
c WATER LEVEL Below Top of Casing 5A
(Use "+" if Above Top of Casing)
NO'
FT
1i
f DISINFECTION Type f , l tt Amount EQozs
g ATER ZONES (dept,h.�)
28216 Top 7)5 Bottom11Kfop Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter We(�,g�ht pMaterial
Top A( Bottom f' 1 1 Ft (� �y ,kin lu' 6 VC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Mterlal ,
Top Q Bottom' ZC Ft IrntC()
Top Bottom Ft
Top Bottom Ft
Method
CWP
9 SCREEN Depth Diameter Slot Size
Top�� Bottom Ft in in
Top /1 I Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
en
9b si;P Crie rcrk
12 REMARKS
Material
Form��e$cription
RFCEIVED
3 I ZU10
Information Processing Unit
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORE _ PROVID@Bd0 THE WELVOWNER
SIGNA
aigL
RTIFIED WELL CONTRACTOR DATE
Of, 1 0.(fl cl`l r
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