382326_Well Construction - GW1_20100409

7,9,7
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACT R R:
ith ► ee_e,e.,
Well Contractor (Individual) N�lne
Welt Contractor Company Name
STREET ADDRESS 9ORg AOrf (e1d s
City or own State
( )- ELK — a.180
2ip Code
' /
�j 9"�+
il✓ i f �`"
Area code- Phone number lsA-
2 WELL INFORMATION, %f
SITE WELL ID Cif applicable) St,6 /
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring* Municipal/Public 0
IndustnaVCommercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED / " P " lB
/
Q' PM ❑
TIME COMPLETED 7�7t AM
3 WELL LOCATION:�J�,��
CITY rd.�fitiQGdll.L� COUNTY
/// � /t / t /v1L
(Street Name Numbers, Community, Subdivision, Lot No , Parcel, Zlp Code)
TOPOGRAPHIC / LAND SETTING
El Slope ❑Valley 4 Flat D Ridge ID Other
(check appropriate box)
LATITUDE 3
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 lopo map and
attached to this form rf not using GPS)
4 FACILITY is the name of the business where the welt Is located
FACILITY ID #(if applicable)
NAME OF FACILITY c „eL.e,I,� _ ./_Q�
//^X
STREET (/, /e /C,G�InErL., 401
2DRESS
.- 4 e C. • pegi,„e6,
City or Town �% State_ od=
CONTACT PERSON /y7�¢i/a'►i
M LI G A D ESS �3 ,
rail`4
�� G . _Y." a?
City or Town State
( ?0fL )- 5Fi 4a07
ip Code
YES 0 NO ■
FT,
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 0 l_c
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
(
3 e.,4Ad
d TOP OF CASING IS • FT Above Land Surface'
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) NA. METHOD OF TEST
f DISINFECTION Type kit k Amount
g. WATER ZONES (depth)
From To From To
From To From To
From To From To
Thickness/
6. CASING. /{
From t DTo' ialt Ft Dlei 6,
6 y�gha
From To Ft h�
From To Ft
T. GROUT, Depth Material);�� Method
From Tq Ft
From To Ft
From To Ft
8 SCREEN. /e th Diameter Slot Size Material
.+yam ,/„ /00°JG
From +7LJ o �0a%t J. In in
From To Ft in In
From To Ft in in
9. SAND/GRAVEL PACK:
Depth��''� �� Size
Material
From—��f�r� /-6�st�`•_�_,�/�.!/a
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
0 44P, f" ceafr
11. REMARKS.
A9?01U
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROANCE1WR4
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THA}T,A COPY OF THIS
REC�RD AS ��„� IDEDTOTH WELL°WNER�r' C40`f `-'
J--P14
IGNATURE OF ' TTFIED • ELL CONTRACTOR DATE
fro,
PRINAM a OF RSO CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality withJn 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No, [phone] ext 568.
Form GW 1b
Rev 7/05