382346_Well Construction - GW1_20100409

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTO
�.ei-71� ¶PE x C
Well Contractor (Individual) Name
�I�4K c O '7-/\1 c
Well Contractor Company Name
190 t ✓V OF 7/-FF-?cD Dig► (JET
Street Address
3 46
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) METHOD OF TEST
f DISINFECTION Type Amount
257o T7/CL SC__ g WATERZOBES(depth)
Top Bottom Top
City yr Town
( �� ) Ski 3' 2.1e.P J
Area code Phone number
2 WELL INFORMATION �p
WELL CONSTRUCTION PERMIT# �`
OTHER ASSOCIATED PERMIT#(if applicable) 700013
SITE WELL ID#(ifapplicable) fttk) 3
3 WELL USE (Check One Box) Monitonng 1g Municipal/Public ❑
Industrial/Commercial ❑ Agncultural ❑ Recovery ❑ Injection ❑
Imgation❑ Other ❑ (list use)
DATE DRILLED — t g -- i 0
State Zip Code
4 WELL LOCATION
Top Bottom Top
Top Bottom Top
7 CASINGH�1Depth
Top -d-M Bottom Ft
Top Bottom Ft
Top Bottom Ft
Bottom
Bottom
Bottom
Thickness/
Diameter Weight
zit
Material
4b Pot
8 GROUT Depth Material�Method
(�
Top 0 Bottom 3 Ft '1 C nl Apof
Top 3 Bottom 4 Ft �j',(,i f'RI(LIS ✓t
Top Bottom Ft
9 SCREEN. Depth Diameter Slot Size
3©�U C-A}STl vr3t/ Q�iLi rlc �� ZO& Top H CBottom 2v Ft 7- in 2).0(C0 in
Top Bottom Ft in in
CITY C $ 44A-R-&-077C COUNTY /h CLCR3' DCA2(Top Bottom Ft in m
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
Material
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑ Other
LATITUDE "DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source IGPS propographic 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 )
Avvl fci & Cc c S
Facility Name Facility ID# (if applicable)
^�
CitStreet Ad(ce` 4 N C G-e3
y City or Town *n State Zip Code
J`�3KC W U -r7cE Q_ A3Scx40-7r- .S
Contact Name
3017 - A —772i OAl2-4 Coo2-7
Mailing Address
Ci4A'co'17t.":"
City or Town
(7O4--) 525—?2oo
C Zru7
State Zip Code
Area code Phone number
6. WELL DETAILS
a TOTAL DEPTH C/-U
b DOES WELL REPLACE EXISTING WELL') YES ❑ Ng,
c WATER LEVEL Below Top of Casing FT
(Use "+" if Above Top of Casing)
10 SAND/GRAVEL PACK -
Depth
Top - Bottom 2r.J
Size Material
Ft CO"L4 - Sly
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
12 REMARKS
Formation Descnptlon
1 @.Ar 1`
Nrn O- L010
morrnation 3- c c3ssing Unit
uvvuiijLii
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 BETA PROVI 'i D TO THE WELL OWNER
SIGNATURE OF CE IFIED WELL CONTRACTOR DATE
7 £PerEccT
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