380481_Well Construction - GW1_20100122

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # a a 13 -
1 WELL, CONTRACTOR:
Are-a2Arre A I I /1i
Qntrac r ( vldual) Name
WeII C
Well ContractorCompany Nam*
PO, ov 29R
Street Address
5'Ffl-i-i��J A),Ci �$0
City or Town State Zip Code
(`20-1) 73-2- �s3c1
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery, Injection ❑
Irngation❑ Other ❑ (list use)
DATE DRILLED / -//- /0
4. WELL LOCATION:
31LtS $ Try bto Si --
(Street
Name, Numbers, Com unity, Subdivision, Lot No , Parcel, Zip``Code)_
CITY C\\ 3 1 b-f +� COUNTY I' leC 1kV�1
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope :Walley r'fat ❑Ridge ❑Other
LATITUDE 36 "DMS OR 3x xxxxxxxxx DD
LONGITUDE 75 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source EPPS Dropographic 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
Faci Name Facility ID# (if applicable)
31 L(5 S , i ryn,t) S+,
Sire t Address
� kr Infi-�-e
City or Town
! JAris iei5 G1� — UZS
Contact Name
State Zip Code
Mailing Address
City or Town State Zip Code
(70i-1) 7/ (v - (77 (v /
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ lye
c. WATER LEVEL Below Top of Casing FT
(Use "+" if Above Top of Casing)
1
I t-1
3f 0 81
d. TOP OF CASING IS FT Above Land Surface"
'Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) METHOD OF TEST
f. DISINFECTION. Type Amount
g. WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Maternal
Top 6 Bottom L/ Ft (o it S'6/l/Q POC-
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top (r) Bottom c2 Ft Cv--m.e., 4- LIP/l7i4Ce
. Top Bottom Ft
Top Bottom Ft
9 SCREEN: Depth Diameter Slot Size Material
Top Li Bottom 1 Li Ft t'D in .O,26 in PVC --
Top Bottom Ft in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK
Depth
Top 3 Bottom 141
Top Bottom
Top Bottom
11 DRILLING LOG
Top Bottom
n l /(1
12 REMARKS:
Size
Ft #3
Ft
Ft
n Material
Formation Descnption
2010
1,V," s L '.lUt,Lt I r JL—L t !UN
Inforrr :ion Processing Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORBEEN PROVIDED TO THE WELL OWNER
SIGNATURE/ EFFTIFIED W LL CONTRACTOR DATE
f2 � ;�
PRINTED NAME 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 : [phone]
/ - /z/-4to
Form GW-lb
Rev 2/09
0