382000_Well Construction - GW1_20100329

105 1-Sa 5
NON ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural ResourceDi visio pf Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL,CONTRACTOR:
‘1( ` WS
Well Con actor Niguel) N e 0
Well Contractor ompanyy'0
Name /
STREET ADDRES l t U 6co D I/ -Ski L
c {c) e A),r
City or Town State
(10'4)- 3C Q1- (SOC1
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(irapplicable) \ 000 I.A5c b
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitonng ❑ Municipal/Public ❑
Industnal/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
IrngatiorOther ❑ (list use) /
DATE DRILLED 3 — 2 Ia— --1C0
TIME COMPLETED AM ❑ PM ❑
3. WELL LTI,,ON/:I f ,(� ,� I ` I,
CITY CQc ✓ U k-f - t? COUNTY A t. eC L 1Oti9U1
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
['Slope ❑Valleyat ❑Ridge p Other
(check appropnate b/�ox)),
LATITUDE 3 �/Cl� t IS 3
LONGITUDE Q St Y Co LP
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ,$PS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form rf not using GPS)
4. FACILITY -is the name of the business where the well is located
FACILITY ID #(If appIIcabl
NAME OF FACILITY LC,
STRE T ADRgs 1 6i�� COL J�(f (,�11 �� (f J ►'�'l t /V t
(7
City or Town State Zip Code
CONTACT PERSON 5a( V\-
MAILING ADDRE i (45
: rQWireJ'Jy�
Iut
City or Town State
)'2) )- �ua� —�.� St)
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH:
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOA
c. WATER LEVEL Below Top of Casing Lin FT.
(Use "+- if Above Top of Casing)
3L1.,
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. R )
e. YIELD (gpm): 1 V 0 METHOD OF TEST
f. DISINFECTION: Type 11 rI e U 0 Amount
g. WATER ZZ` N S (depth) d
(
From o�To ?-4 - Z,IIDorn To
From vl o %CO ( from To
From (P dSTo COCO From To
6. CASING:
1 Depth,� Diameter Matenal
From To —1 OFt
From To Ft.
From To Ft
7. GROUT: Depth Matenal
From () To uO Ft
From To = Ft
From To Ft.
6. SCREEN: Depth Diameter Slot Size Material
From To Ft in. _ in
Flom To Ft. in. in.
From To Ft. In. in.
9. SAND/GRAVEL PACK:
' Depth Size ' Matenal
Thickness/
Weight
pMethod
From To
From. To
From \ To
10. DRILLING LOG' "'
From To
11. REMARKS:
Ft
Ft.
Ft.
Fo -tion 1-scnption
2 9 2010
,.y, ve,OG
DO HE IIE Y CERTI THA THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCCggbbC C, WEL CONS UCTION STANDARDS, AND THAT A COPY OF THIS
RECOR S BEE ROVI D TO THE WELL OWNER,
SIGN() URE OF C RTIFIED WELL CONTRACTOR DATE
aU Siv1 �pl s
PRI ED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center — Raleigh, NC 27699-1817 Phone No. [phone] ext 568.
Form GW-lb
Rev 7/05