383441_Well Construction - GW1_20100513

3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial 0 Agncultural ❑ Recovery ❑ Injection ❑
Imgation❑ Other 0 (list use)
DATE DRILLED LC-c).-1 - Lb
4 WELL LOCATION
'a i D D I & eel Cz C/t 'K Iz
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY C In. AIL-6z) tt c COUNTY M ECV IL'J h
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley rFlat ❑Ridge ❑Other
LATITUDE 03° U8 "DMS OR DD
LONGITUDE dP& ° 9{.' (tit /3 " DMS OR DD
Latitude/longitude source (V PS Qropographic 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 )
c ec &' . Fc—R.,`1 (_A),
Facility Name �_ / Facility ID# (if ap�licable)
3E0 0lei 1 C�c l C-' ciLt-6-4e- 2 Q/
Str et Address
City or Tolwn State Zip Code
IpC�/AfL O/�
Contact Name C�-c cy i2
c„ 3 a 4( PA" 01
MailingAddress
C,4AI(©4 dj e. a8a 10
City or Town State Zip Code
("70 () 3 6 a. -- 6 3ir
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL'S AYES ❑ 7 NiDg
c WATER LEVEL Below Top of Casing a tY • D J( FT
(Use "+" if Above Top of Casing)
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELiL ONTRACTOR
EL9,a C3. �IEf�,rz,J
Well Contractor (Individual) Name
IAA_ 4c(O /L lD /W Ut i NS
Well Contractor Company Name
d56 I? T-rut porch" ttctc
Str et Address
c,its r I(r 144., 3s806
City or Town State Zip Code
) -zoo b
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# W M 0300 57 r,
OTHER ASSOCIATED PERMIT#(ifapplicable) /0 / fy
SITE WELL ID #(if applicable) O FF ft& LO #- S
«78 -
30
d TOP OF CASING IS d 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 @,-a . Bottom B-C Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Sat Weight Material
' Top 0' Bottom / D r Ft C9 u (it) P 1/ L
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth f Matenal p Method
Top �:5 Bottom --7.,.._
Ft to ' yex-i' fs - q NA-tJ! �'i
Top 1 1 Bottom 5'.5' Ft C6iu C-4.—C)Q7C6 6 f'ta LfT — r I i C
Top Bottom Ft
9 SCREEN Depth Diameter
I
yq ^
Top fY 0 Bottom a Ft O. in
Slot Size Material
O 0 In t" ti C.
Top Bottom Ft in in
ar_t_c Top Bottom Ft in in
10 SAND/GRAVEL PACK
ezi Depth / Size Material
. Top .• Bottom 015 Ft / g41/
Top
Top
Bottom
Bottom
11 DRILLING LOG
Top Bottom
moo' /d5'1
/
/
/
12 REMARKS
Ft
Ft
Formation Descnption
11lit// c6
s1 p /L.tn Grp
E
MAY 1 3 2n10
Information Pioc :sstng Unit
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NGA C 2C WELL CONST�RRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOND HAS BEEN PROVIdED TO THE ELL OWNER
SIG ATURE OF CERTIFIED WELL CONTRAC--T/IOR
I,, (.3 I A) 8. to G-10 iZ..(t t.•
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 (919)'807-6300, =
DATE
Form GW-lb
Rev 2/09