380813_Well Construction - GW1_20100202

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®N zE `_ SIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3572
1. WELL CONTRACTOR:
Chris Moraan
Weil Contractor (Individual) Name
Morgan Well & Puma. Inc.
Well Contractor Company Name
4070 Sunrise Drive
Street Address
Kannaoolis
City or Town
(704 ) 933-0479
NC
State
28083
Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 10000,43C(1
OTHER ASSOCIATED PERMtT#(If applicable) n/a
SITE WELL ID #('dapplicabte) n/a
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Indus(nal/Commercral 0 Agncultural 0 Recovery 0 Injection 0
Imgationl�Other 0 I- use)
DATE DRILLED 1 /'3 0
4. WELL LOCATION: t1 4 ., / - - - - 9. SCREEN: Depth Diameter Slot Size
M7
Top Bottom Ft
d. TOP OF CASING IS 1
`Top of casing terminated at/or
a variance in accordance with
e. YIELD (gpm):
f. DISINFECTION: Type
ZONES (depth), WATER b
Top b Bottom 3)
• Top Bottom
- Top Bottom
METH
FT Above Land Surface*
below land surface may require
15A NCAC 2C 0118
D OF TEST Air Pressur a
Amount? Z�
Top
Top
Top
. 7. CASING: Depth Diameter
- Top O Bottom FL 6 1/8
Top Bottom FL
• Top Bottom FL
8 GROUT: Depth
Matenal
Top 0 Bottom 20 FL Cement
Top Bottom Ft
. Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
Weight Material
SCH80 PVC
(StreefName, Numbers. Community, Subdivision, Lot No . Parcel, Tip Code) L Top Bottom Ft
CITY- V i c/60,1 COUNTY Meek/MA/9 ' Top Bottom Ft.
TOPOGRAPHIC / tAND SETTING_ (check appropnate box)
❑Slope ❑Valley afTat ❑Ridge ❑Other
LATITUDE °40 • Sari " DMS OR 3X.)00000000(DD
LONGITUDE) ° 4 ' Spey" DMS OR 7X.x7 00000c7oC DD
Latitude/longitude source- MPS 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 )
f t f - n/a
Facility N9LmFacility ("rf pph e)
t+ 1 � 7 v�d50n-10ncolity I
Street Ad
- 10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft
Top Bottom FL
Top Bottom Ft
in.
m
in
Size
11. DRILLING LOG
• Top_ Bottom
V id50/) Nc 2EC34 : l
Method
Gravity
In
In
in.
Material
Material
City o Town State Zip Code / — ire in" fl
re' I3r idge '� /
Contactry
1 �'l [i 7 i-v dSon-/ 0fro L
6
Maths dress /
I .5c n NC u,3,(
City or Town State Zip Code
(7O1L( ) 6"--64 s
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
700'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing t �Q FT
(Use -+" d Above Top of Casing)
• 12. REMARKS:
FFF302
Ldt
voiNTE-.,t3 Unit
InforrnDUuuie ,:,
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A N •-• 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO7) ,— BEEN jr DED TO THE 4)/E O NER
•
• SIGNATURE 0 CERTII EO WELL CONTRACTOR
: Chris Morgan
PRINTED NAME OF 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]
Form GW-lb
Rev. 2109