387732_Well Construction - GW1_20100930

NON RESIDENTIAL WELL cONs., Ruc-I ION RECORD
North Corotina Department of Fnvrranment mid Natural Recnurcec. I tivrtion of V1 ate!' Quaid)
WELL CONTRACTOR CERTIFICATION tl 3oo2.A
1. WELL CONTRACTOR:
RAtiwt L. ID w�
Well Contractor (Individual) Name
ClAdoi.A,41 (ADEu
Well Contractor Company Name nn
STREET ADDRESS . to1Ll CiletwiIAA.
SY1000.0F ac
2biIL
City a Town State Zip Code
( 16 Y )• 140 4- 803 5
Arse code- Phone number
2. WELL INFORMATION:
SITE WELL ID 11(11 appecebie)
STATE WELL PERMITe(tr applicable)
DWQ a OTHER PERMIT tl(if applicable)_, l000t!'11(1
WELL USE (Check Applicable Boa) Monitatng i;7 Municipal/Public f I
IndustrlaVConimerclsl0 Agricultural n Recovery 0 Injection fl
Irrigation° Other 0 (IMt use)
DATE DRILLED 24p- (O
TIME COMPLETED 5'00
3. WELL LOCATION:
CITY Co(La+irukAS
AM O PM Ei
COUNTY IVIE kEr+Bkl1G
WESt LA—AL./a, Ave Na
BtNS (Street Name, Numbers. Community Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC 1 LAND SETTING
()Slope °Valley elat (]Ridge 0 Other
(dick appropriate box)
LATITUDE .L _ ? 21. S& rJ
LONGITUDE 92 53.290W
Ma) be in degrees
minutes, seconds or
in I decimal format
Latitude/longitude source: p'GPS °Topographic map
(location of will must be shown on USGS topo map end
attached to this form B not ushg GPS)
4. FACILITY. is miming of the Wetness where the well M speared
FACILITY ID R(14 applicable)
NAME OF FACILITY
STREET ADDRESS
City or Town State Zip Code
CONTACT PERSON Jtrw.+„+t Rut t itS
MAILING ADDRESS Ici Ib so..,4-4, vd 51, i-e cW
rharbilv
City or Town State Zip Code
(?Mg )..-3SE-4WD
Are* code • Phone number
If. WELL DETAILS:
a, TOTAL DEPTH: Boo
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO '
c, WATER LEVEL Bela,/ Top of Casing 4o FT
(Use'•' it Above Top of Casing)
d TOP OF CASING 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 (gpm) .,_._.30 METHOD OF TEST A.
DISINFECTION Type 10°/o (4M Amount 41S 0%•
g WATER ZONES (depth)
From 21oo To From To
From 3SD To From To
From 1010 To From To
6 CASINO.
pth Diameter
from b To IL5 FI FI L0'ISs",
from To
lion, _-DeTo Ft
7 GROUT Depth
From_ 0 To 3 FI
From 3 To tot FI
From To Ft
6 SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK'
Depth
From To Ft
Thickness/
Weight Material
Material
Po(2XL.Arte
RENT°'+tTF
Diameter
Method
Gµa•
Slot Size Material
Ft In In
Ft in in
Ft in in
From To Ft
From To Ft
10 DRILLING LOG
From To
0 Icr
Iq 8g
$r} 12o
lZo goo
11. REMARKS.
Size Materiel
Formation Description
Reis lb,4T
&Zowr Ut¢T /Sfb+D
QR,+ COY POC-44
&or, lir
• D
SEp 30 ��
2010
voirlapOn Prnrn
uvv0/80G "'y Unit
'WHEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTEDN ACCORDANCE WITH
t SA NCAC 2C WELL CONSTRUCTION STANDARDS ANO THAT A COPY Of MS
RECORO HAS BEEN PROVIDED TO THE WELL OWNER
tC.l O
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
CRArAiLtE L. O i_W R
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
-2-to
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GWlb
Rev 7)05