383440_Well Construction - GW1_20100513

.NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- D,rision of Water Quality
WELL CONTRACTOR CERTIFICATION # (Y7
1 W L CONT TOR.
>ry E3 14c-� fL( CR—
City or Town
(5) 85 a -- 0015
Area code Phone number
2 WELL INFORMATION.
WELL CONSTRUCTION PERMIT# W 6300 5i
Well Contractor (Individual) Name
0/.A j e,/L --/�.1,ll i (" 0.5
Well Contract C mpa v Name �J
LC(' . �tspa C:rLcQE
St et Address
10.,,Tk 01 t(c1: 4c 3580cv
State Zip Code
OTHER ASSOCIATED PERMIT#(irappliwoe) A.VA
SITE WELL ID #(if applicable) 0 FF Nl'lr(7 •
3 WELL USE (Check One Box) MonitonngMunicipal/Public ❑
Industrial/Commercial 0 Agncuftural 0 Recovery ❑ Injection ❑
Imgation❑ Other l❑ (list use)
DATE DRILLED "c '9-3- 1 0
4 WELL LOCATION
a3 t © Oa 5tz--l` (e Cn —1 ' i2dO
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
�
IT CY �VLikd I/J e
3:;3 t40
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 N. (ow` Bottom' p SI Top Bottom
•Top Bottom; Top Bottom
: Top Bottom Top Bottom
i
Thickness/
7 CASING: Depth Diameter Weight Material
Top 6( Bottom ),0( Ft a `t ScQ t(0 Pk (.
• The Bottom Ft
Top Bottom Ft
8 GROUT Depth ' Matenal Method
. Top f Bottom S(g. E- Ft C&iltrAf I�r�c6—cite f — ci���tl!
Top cos" Bottom 0, CV Ft - C ki6tS _ J /t/1?t'- Y /
Top Bottom Ft
9. SCREEN: Depth Diameter
Top Id Bottom
Top
.d COUNTY/LLeCt�I•f'�+� �� Top
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley .Flat ❑ Ridge ❑ Other
LATITUDE al135 ° la ' W. i'-) " DMS OR DD
LONGITUDE 080 * g(' kit("(.AJ DMS OR DD
Latitude/longitude source PS Qropographic map
(location of well must be sho on a USGS topo map andattached to
this form if not using GPS)
5 FACILITY (Name of the business where the well is located )
6 6-o E E. Fe,t u
Facility Name Faal ( ID• # If a )
3 to old gt Cuff parable
Stre t Address
c.VLA AA 0 tie- , C
Cityfor Town / q State Zip Code
0'C C" . CQ / AO /1-0 /V
Contact Name
(G 3 9..- Li r= /v.el- v • e--c„ct Rd -
Mailing Address
c2 / -t i'-
City or Town
(?o(1) • G5G
Area code Phone number
6 WELL DETAILS
a. TOTAL DEPTH
Q 5/
N C a&a/D
State Zip Code
b DOES WELL REPLACE EXISTING WELL'' YES 0 NOO
c. WATER LEVEL Below Top of Casing 14. (qG FT
(Use "+" if Above Top of Casing)
r7 ✓ Ft a' m 010 in
Bottom Ft
Bottom Ft
10 SAND/GRAVEL PACK.
p( Depth St
Top O Bottom Ft
• Top Bottom Ft
- Top Bottom Ft
11 DRILLING LOG
Top Bottom
6' / ast
/
12 REMARKS
In In
m m
Slot Size Material
pv L
Size Material
( &414,0
Formation Descnption
S; l� y ('la
IrN
MAY Y S LU IU
Information Processing unit
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS
15A NC f{C 2C, WELL CONSTRUCT!
RECQfjb HAS BEEN PRBVIDED T
ELL WAS CONSTRUCTED IN ACCORDANCE WITH
N STANDARDS AND THAT A COPY OF THIS
HE WELL OWNER
SIGNATURE CERTIFIED WELL CQNTRACTOR , DATE
�i �1
L or 2 ( c
PRINT 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 2/09