382329_Well Construction - GW1_20100409

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ogCp
1 WELL CONTRACT R R
nth It t ee.l✓e..,
Welntraclor (Individual)e
Well Contractor Company Name `
STREET ADDRESS gORg J.Qr
1
lelr tr.
t-or-t) Nq S0, Q1107
State
Citr swn also
1
Zip Code 7(45)f
Areaco e- Phone number
rea
2 WELL INFORMATION
SITE WELL ID #(if applicable) S�b
�y `% h�✓j n�
�
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT Cif applicable)
WELL USE (Check Applicable Box) Monitoring
Industrial/Commercial 0 Agricultural
Irrigation0 Other 0 (list use)
sp. MuntcipaVPublic 0
0 Recovery 0 Injection 0
DATE DRILLED 7 -dse-/O
ly- PM O
7i�
%�4.4,
TIME COMPLETED ` f cJ 0 AM
3 WELL LOCATION:
COUNTY
CITY Cie/4 C L�
//4 /t ire 1.1.4 ---
(Street Name Numbers, Community, Subdivision,
TOPOGRAPHIC / LAND SETTING
OSlope °Valley ®Flat °Ridge
(check appropnate box)
LATITUDE ,,
Lot No , Parcel, Zip Code)
p Other
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE
Latitude/longitude source ■GPS °Topographic map
(location 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 #(if applicable)
NAME OF FACILITY �y X ?�
iQ�
L.,aLeL�f
STREET A DRESS //D /,1 /LaG P� I"o`—
- ie c , o?8F69
City or Town �,- �Statei od
CONTACT PERSON %9iyyyz'L
Ivt_ I G A D ESS�1
City or Town State
(70cl')- .571 44aa7
ip Code
YES 0 NO
__FT
Area code - Phone number
5 WELL DETAILS' /�/
a TOTAL DEPTH (}/�
b DOES WELL REPLACE EXISTING
c WATER LEVEL Below Top of Casing
(Use'+' if Above Top of
WELL?
1
Casing)
d TOP OF CASING IS • FT Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e, YIELD (gpm) NA, METHOD OF TEST
f DISINFECTION' Type )J/Q.,. Amount
g. WATER ZONES (depth)
From To From To
From To From To
From To From
To
6. CASING: Thickness/
/‘ [
// DToll/ Ft D�r er SCIj 9ht /yp�
From
From To Ft -
From To Ft
7. GROUT' Depth Material Method
From 0 To Ft � %� IG( -� 4 eir. .
From To Ft
From To Ft
8. SCREEN: Depth Diameter Slot Size Matenal
••
From To Ft in /D in iat
From To ' Ft in in
From To Ft in in
9 SAND/GRAVEL PACK:
Dept Size
�s Material
From To Ft oC ,II¢d/t
From To Ft
From To Ft
10. DRILLING LOG
From To Formation Description
0
11 REMARKS:
267u
Infprota/ , , ,
DVv` io'; "hig Unit
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wrni
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
REC,QRD i kS EE L ayIDEO TO THE WELL OWNER
IGNATURE OF L'ERTIFIEDELL CONTRACTOR DATE
PRI TED NAM OF RSOON 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 568.
Form GW tb
Rev 7/05