387733_Well Construction - GW1_20100930

NON RESIDENTIAL WELL CONS1 RUCs ION RECORD
North Caroline Department of Environment and Natural Rctntirce‘• I )tvtann of .\ ntcr Quaid)
WELL CONTRACTOR CERTIFICATION N 2002.A
c
1, WELL CONTRACTOR:
PAOWIE L• O'met-
Well Contractor (Individual) Name
CAO4L.toR WELL '-DQ.i L l rto
Well Contractor Company Name
STREET ADDRESS (o(DI4
MO'JP E piG n112-
City or Town State Zip Code
( 1oti } •71o4'FsoBS
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID Ofif applicable)
STATE WELL PERMITN(II applicable)
DWQ a OTHER PERMIT N(iI applicable)_-_ 1000411 e1
WELL USE (Check Applicable Box) Monitoring (3 MunicipalPublic ( I
IndustrlaVCommerclal 0 Agricultural C7 Recovery 0 Injection F1
Irrigation® Other O (Nat use)
DATE DRILLED g- 25- to
TIME COMPLETED 5 = co
3. WELL LOCATION:
CITY Co(L)rELAiA5 COUNTY ttnerxl.E08v06
11911 l,ss CATAw3A AVE. Nag.1#1S PAael
(Sheet Name, Numbers, Communiy. Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC 1 LAND SETTING
OSlope ❑VOney dFlat °Ridge ° Other
(check appropd.te box)
LATITUDE .• 5° 25.487 N
LONGITUDE , , O° 53. 210 W
AMID Mid
Me) be In degrees
minutes, seconds or
in a decimal format
Latitude/longitude source: elGPS °Topographic map
(bcetbn awe! must be shown on a VSGS topo map end
attached to this Porn M not using GPS)
4. FACILITY• n theme of h business Whiff the wee is tasted
FACILITY ID N(11 epplIcable)
NAME OF FACILITY
STREET ADDRESS
City or Town State (� Zip Code
CONTACT PERSON S t eno a t.rt lbw t.DtRS
MAILING ADDRESS 19 I D ,5tu j4 B)1K1 Swi-e (ACO
rhr Flo-l#e j\iC:
City or Town State Zip Code
)• 353 - g94T)
Area code • Phone number
5. WELL DETAILS:
e. TOTAL DEPTH: ?Co'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO btf
c. WATER LEVEL Beiv14 Top of Casing ito FT
(Use '+' If Above Top of Casing)
d TOP OF CASINO IS 1 FT Above Lend Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (pm) 10 METHOD OF TEST AV
-
I DISINFECTION Type
g WATER ZONES (depth)
From 240 To
t4 t Amount 48 02.
From
From
6 CASINO
To
To
Depth Diameter
From 0 To $O FI Id118".
From To Ft
- -- From To Ft
7 GROUT Depth
From 0 To 3 rt
From 3 To2o Ft
From To Ft
8 SCREEN: Depth
From To Ft in
From To Ft in
From To Ft in
9. SAND/GRAVEL PACK'
Depth
From To Ft
To Ft
To FI
From
From
10 DRILLING LOG
From To
O 11-
12 So
So IDS
(oS Soo
11. REMARKS:
From To
From To
From To
Thickness/
Weight
Sb1L 2►
Material
Po¢Tt.Arso
ekoTorkive
Material
p �c
Method
p4•�P
Diameter Slot Size Material
In
in
In
Size Materiel
Formation Descnptlon
REo Dl(Lf
t3Ra.+.. -0 ►cis /c-as1
&Uri SP"D
gar►TE
m_....t•_a I r
v 1-T 5 O
ZUm
Information PioCOss)ng Unit
DWQ/BOP,
100 HEREBY CERTIFY THAT MS WELL WAS CONSTRUCTION ACCORDANCE Wml
ISA NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY Or THIS
RECORO HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR
l'vI►rl�lE L . ouw2tl
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
P, 1-to
DATE
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center — Raleigh, NC 27699.1617 Phone No. [phone] ext 588.
Form GWib
Rev 7105