381020_Well Construction - GW1_20100215

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2213-A
1. WELL CONTRACTOR:
Barry McAloin
Well Contractor (Individual) Name
Mad Dawa. Inc.
Well Contractor Company Name
PO Box 398
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitonng Municipal/Public ❑
Industnal/Commercial p Agncultural Recovery ❑ Injection ❑
Irngation❑ Other ❑ (list use)
DATE DRILLED ( —/y — /©
4. WELL LOCATION:
S4-15 (Cite i (-00/L 12c)
(Street Name, Numbers, Comnity, Subdivision, Lot No , Parcel, Zip Code)
CITY 0-r- (O T-'1—e COUNTY I c- LI'
TOP RAPHIC / LAND SETTING (check appropnate box)
lope ❑Valley ['Flat ❑Ridge DOther
LATITUDE 36
" DMS OR 3X XXXXXXXXX DD
ie'fi
1: t)�_
i
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)
NC 28080 Top
State Zip Code
LONGITUDE 75 " DMS OR 7X.)00o0XXXx DD
Latitude/longitude source QGPS Dtopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
✓V4ec 1 e �o. (otl-PU, it 12r) (Ai C,(05 031
Facility Nam / JJ FacJ�ty+D# (if applicable)
Street Address (1 O 1 AIL
Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 C S G: Depth Diameter We f lit Material
Top Bottom Ft 0 i` Sgo
PvC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal
Top O Bottom q Ft C•tohve/1 A -
Top Bottom Ft
Top Bottom Ft
Method
9. SCREEN: RREEN: Depth Diameter Slot Size Mlatte�rii
Top 9 Bottom a LI Ft d in I O lOm P"
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK:
Depth Size
Top 7 Bottom of q Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
6. FACILITY (Name of the business where the well is located) Top Bottom Formation Descnption
-4)rl/
Materaa
ceA—„)
0 /
41_
/
,
City or Town /� �/ to Zip Code /
s MC PC- r//GJL- L is c L /
Cola N?Te J o U i✓ / fn`� 8 (4 • /
Mtn?t,r1: {-( N•c, s 273 /
City or Town State Zip Code
( �6111) <59s3 -?2Co
Area code Phone number
6. WELL DETAILS: 'r
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ DKu
c. WATER LEVEL Below Top of Casing FT
(Use "+" if Above Top of Casing)
12. REMARKS:
RECEIVED
I Lu 1 2010
Information Processing in
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2CELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD ;.r BEEN PROVIDED TO THE WELL OWNER
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
_[2 /
DATE
Form GW-lb
Rev 2/09