382333_Well Construction - GW1_20100409

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ays t.
1 WELL CONTRACTQR,
nth
Well Contractor (Individual) N
S haAc.CJ
Well Contractor Company NameetSTREET ADDRESS gUpg
eta
( RCS)- ELK- also LS/# /7
Area code- Phone number
2 WELL INFORMATION ./'
SITE WELL ID Of applicable) �I�Dfit4' ' 7RJ7 /
STATE WELL PERMIT#(If applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED
TIME COMPLETED // Je AM Lal PM ❑
3 WELL LOCATION. ,,//
CITY (�.�1/t� COUNTY %%Z.1..e
/1)/4 /lam -
(Street Name Numbers Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope :Walley E Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source in GPS ❑Topographic map
(location of wed 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 wet Is located
FACILITY ID#(if applicable)
NAME
NAME OF FACILITY,///�/�
STREET ADDRESS !! Q
G , pe,,,FG
�-�� / od
CONTACT PERSON %� /0 z'
City or Town State
M,}. Ll AA D ESS
City or Town
(70 ) 5FI
Area code - Phone number
f l I
State
0a07
5 WELL DETAILS ��
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL?
YES 0 NO
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
3
yt oh
�- f✓ 'LI
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) N/Q. METHOD OF TEST
Amount O.
f. DISINFECTION. Type
g WATER ZONES (depth)
From To From To
From To From To
From To From To
6 CASING: Thickness/
0 Depth ter W lit a
From V To 3PDi •rFt 56 9
From To Ft
From To Ft
7. GROUT: Depth Material;�,�� Method
From 0 To�Y# Ft d �tr�"_'�� ' riW '
From To Ft
From To Ft
8, SCREEN Depth r Diammeter Slot Size �OMMatenal
From 30 To 1J Ft d / in /1 in V , _
From To \ Ft in in
From To Ft in in
9. SAND/GRAVEL PACK:
Depth Size Materiaall
FromTo FI.L ,��.!/LZ
From To Ft
From To Ft
10. DRILLING LOG
From To
Q
11 REMARKS.
Formation Description
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WrrH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD ASIDEDTOTH(WELL OWNER
IGNATURE OF 'TIFIED
.1-4o /o
ELL CONTRACTOR DATE
fej$
PRI EAM OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center — Raleigh, NC 27699-1617 Phone No, [phone] ext 568.
Form GW lb
Rev 7/05