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HomeMy WebLinkAbout382346_Well Construction - GW1_20100409NONRESIDENTIAL 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 : (919) 807-6300 Form GW-lb Rev 2/09