380482_Well Construction - GW1_20100122

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carohna Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # as ► 3 - 4
1. WEI,�LL,,CONTRACTOR:
'4Alz VYlcP
Well Cont ctor i dividual) Name
±i G_L-u1-roc
Well Contracjgr Company Mme�y
P.o. (60x 291 [5
Street Address
3`'0 82
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
in g. WATER ZONES (depth)
mpO p�O •Top
City or Town State Zip Code
( XY-/) 73 a - x 3 a /
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) Monitonng‘Municlpal/Public 0
Industnal/Commercial ❑ Agncultural 0 Recovery 0 Injection ❑
Imgation❑ Other ❑ (list use)
DATE DRILLED 1- //
4. WELL LOCATION:
31 t4 $ r yo,t) Sf-
(Street Name, Numbers, Cormmm -pity, Subdivision, Lot No , Parcel, Zip Code)
CITY COUNTY YAeC1de-A1
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 36 " DMS OR 3x xxxxxXxXX DD
LONGITUDE 75 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source BPS :Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Nameofthe business where the
well is located )
i 0- Ot \\CAA oYl � ` S Ob S -Ctel
Facility Name Facility ID# (if applicable)
(ys s, Try() s
Stp.� Address 1�
N,<<
City or Town
Contact Name
State Zip Code
- Uf2S
Mailing Address
City or Town
( 76L) -) / (o - 0-264
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO)
c. WATER LEVEL Below Top of Casing FT
(Use "+" if Above Top of Casing)
Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING: Depth Diameter Weight Material
Top 0 Bottom g Ft a i t CLVd PV L
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenai '/ Method
- Top 0Bottom q Ft c? nevi 1 >.e-t`Q1
Top Bottom Ft
Top Bottom Ft
. 9. SCREEN: Depth Diameter
Top Bottom a3 Ft a !
Top Bottom
Top Bottom
Ft in
Ft in
10. SAND/GRAVEL PACK:
Depth Size
- Top (0 Bottom 93 Ft
Top Bottom Ft
. Top
Bottom Ft
11 DRILLING LOG
• Top Bottom
of a3
/
/
/
/
/
/
/
12. REMARKS:
/77 - L)J
Slot Size
in i bl O in
in
m
Matenai
Material
t tie
Formation Descnption
gel', I
i Frs
JAN 2 2 2010
Imorrr-,on rrocessinn I Init
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2 ELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD J BEEN PROVIDED TO THE WELL OWNER
/- / / /D
SIG 'A RE 0 i ERTIIED WE CONTRACTOR DATE
PRINTED NAME OF PE SON 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]
Form GW-1 b
Rev 2/09