382334_Well Construction - GW1_20100409

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # DgSP
1 WELL. pCONTRACT
R. eel Q
Well Contractor (Individual) Nine
SA12AfT,A
Well Contractor Company
STREET ADDRESS
&r-t, IY i
Name
gORE
0
�rf r ddk'.
ac9 07
(� City or ownState
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E
Zip Zip C e
4,5'It 00
/ ry13
A�c)._rea e- Phone number
#TION
2 WELL INFORMATION
SITE WELL ID #(If applicable)
STATE WELL PERMIT#(If
DWQ or OTHER PERMIT
WELL USE (Check Applicable
Industrial/Commercial 0
Irrigationp Other 0
DATE DRILLED ti
��!!''
1664' 79,....77
applicable)
#(if applicable)
Box) Monitoring,
Agricultural
(list use)
Municipal/Public 0
0 Recovery 0 Infection 0
-1/-
❑ PM air
#4.[JC.
TIME COMPLETED / D(i AM
3 WELL LOCATION.
CITY( 4..h?G
COUNTY
-�►—
1
l �� /
(Street Name Numbers,
TOPOGRAPHIC / LAND
0Slope ❑Valley *Fiat
(check appropriate
LATITUDE ....3_
LONGITUDE
Latitude/longitude source
(location of well must
attached to this form
4 FACILITY is the name of
FACILITY ID Cif applicable)
NAME OF FACILITY//e
Community, Subdivision,
SETTING
❑Ridge
box)
Lot No , Parcel, Zip Code)
0 Other
May be in degrees,
minutes, seconds or
in a decimal format
■GPS ❑Topographic map
be shown on a USGS topo map and
If not using GPS)
the business where the well Is located
X
STREET 2DRESS
/// Q //.G�/nP�L-'�G'e�
f /
City or Town
CONTACT PERSON
M LI G A D ESS
State,,___State
'L
I
od:
i
3
•
//State
City or Town
( 70 f4 )- 50PP Oa 0 7
ip Code
YES 0 NO 1
FT
Area code - Phone number
5 WELL DETAILS'
a TOTAL DEPTH C(�
b DOES WELL REPLACE EXISTING
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of
WELL?
Casing)
T
s, A
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) Ida. METHOD OF TEST
f DISINFECTION. Type/tip Amount
g WATER ZONES (depth)
From To From To
From To From To
From To From
To
6. CASING' Thickness/ AI �s
D Depth ry0 Ft Dimr V6+i9h�Q "M
From To ,f
From To Ft
From To Ft
7 GROUT' Depth�j Material Method
Method
From 0 To �JO Ft �� � 2Z i1 ' P�1 we.
From To Ft
From To Ft
8 SCREEN. Depth Diameter Slot Size ,Q/Malenal
From 3e To f4 Ft 7.9 in G in (/ f
From To \ Ft in in
From To Ft in in
9. SAND/GRAVEL PACK:
Depth Size Material
From ID To Ft f/fild
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
11, REMARKS:
!.
09 7010
tnformattc.i Pr c3 Seng Unit
v V V ••..�
I Do HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE wmi
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECQRD S __.! IDEDTOTHI WELL OWNER
ELL CONTRACTOR DATE
PRIRSON 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 1b
Rev 7/05