383442_Well Construction - GW1_20100513

NON ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -// Division of Water Quality
WELL CONTRACTOR CERTIFICATION # q V l g_ E
1 wf4L`CUN a CTOR E r in tz, l N/
Well Contractor (Individual) Name
0,4 ©2
Well Contractor Company Name
S 6 f wk IZ 1 0 -/
C 1 /l d
Street Address
1-40-10 -s Usflf
,ram
City or Town State
(as(,) &5 - 7 O
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# (U M O3OO s L4
3 S S7o,
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) 0)74
SITE WELL ID #(if applicable) (9 r P / ^A ►'4 7
3 WELL USE (Check One Box) Monitoring Municipal/Public 0
Industrial/Commercial 0 Agncultural 0 Recovery ❑ Injection ❑
Imgation❑ Other (list use)
use)
DATE DRILLED " Lq / 0
4 WELL LOCATION
6 3/ 4 orb cre----e e e- j_ 1
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY C CIA R I Olt e IJ. (. COUNTY IItt e& / L4Z
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑Valley XFIat ❑Ridge ❑Other
LATITUDE ���" Z ' /J " DMS OR DD
LONGITUDE Reo 9i ' aa" 6t, " DMS OR DD
Latitude/longitude source $PS ['Topographic 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 )
&iC©.- C. Ferw ( -
Facility Name
03 10 did
Street Aess
II fi � dd iifC
City o; Town
Facilrty ID# ( pplicable)
S'j"`C---C-=l C(2ec`'ft-- %ZC
tGA-no /v
Contact Name
State
Zip Code
Marling Adciress
City or Town State
("?off) ?t,a-- G Id
Area code Phone number
6 WELL DETAILS [/
a TOTAL DEPTH ( T
b DOES WELL REPLACE EXISTING WELL'S
c WATER LEVEL Below Top of Casing
9-016
Zip Code
YES ❑ NOI
1 FT
(Use "+" if Above Top of Casing)
-
b N a)
f `t_ r 2
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 r7 t Bottom (9-4 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Q Diameter Weight Mate/rial
Top Q Bottom f t Ft 0 �` S �� C 1t
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 9 / Bottom
- Top 1 ! Bottom
Top Bottom
9 SCREEN: Depth
. Top 9' Bottom a
tTT7 Matenal � // Method
FtYCNtu
fO+ ' Cl: cp.CI�'/L¢-0f
Ft C FwC41 i3C-cI1 g/l.4` I r t)'LGi6
Ft
Diameter Slot Size Material
Ft - in c0/0 in W1.
Top Bottom Ft in in
• Top Bottom Ft in in
Top 7'
10 SAND/GRAVEL PACK
Depth Size 14 Material
Bottom 9-t `7 Ft / C(N a
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/ lglr
1
i
i
Formation Descnption
e(�y r
aitJ/
5-D g sA /J 4,0 b 'f
1
-
-
MI Y 1 3 201.0
12 X.ElliT6RKS rj
.r30rr1�-V'It�Go/ was oict[C-0 nt,o
ScA-(0-0 W/74 C A.ffe,V? ems/ s
I DO HEREBY CERTIFY THAT THIS ELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A N C 2C, WELL CONSTRUCT! STANDARDS AND THAT A COPY OF THIS
ROD HAS BEEN PI3DIDED TO HE WELL OW ER
IF 07-o—` D
S ATURE OF CERTIFI D WELL CONTCTOR DATE
60,A E. -1-Ae(!J(ZLciL
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within. 30 days of completion to: Division,of Water Quality
161iMail Service Center, Raleigh, NC 27699-161; Phone : [phone]
Information Processing, -
Form GW-lb
Rev 2/09