383881_Well Construction - GW1_20100526

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NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural ResoDtvisio pf Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL
TRACTOR:
S"e S
Well Con aCor iwdu i) Name
r0 5'
Well Contractor ADDREs rlpany Name
STREET f..:( -10 (�aolLsi_�k_
C(ce C.
City or Town State
(-1(-)_ 3Qta — ( SoCO
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(ifapplicable) \ 000 1.,A5b(1)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitonng 0 Municipal/Public 0
Industnal/Commercial 0 Agricultural 0 Recovery 0 Injection 0
frrigatiorp-Other 0 (list use)
DATE DRILLED 3 — I i — ) �CP
TIME COMPLETED
3. WELL L TION:I f i
CITY: C� d It e_
Zip Code
AM❑ PM❑,I
COUNTY /1AeU! �ot6.)
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley {at ❑Ridge 0 Other
(check appropriate box)
LATITUDE 3 /�O IS i
LONGITUDE Q St1! CP L-IU
Latitude/longitude source:
May be in degrees,
minutes, seconds or
in a decimal format
S ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4. FACILITY -is the name of the business where the well is located
FACILITY ID #(if appllcabl
NAME OF FACILITY a{C W
RESS
04
City or Town
CONTACT PERSON y�
MAIL ADDrE L 5 ���jj1'x row t 4 1 ud
City or Town State Zip Code
333881
State Zip Code
6?),o1) -LA 5 an
Area code - Phone number
b. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 N0*
c. WATER LEVEL Below Top of Casing. Lin FT.
(Use "+' if Above Top of Casing)
d. TOP OF CASING IS I FT. Above Land Surface"
`Top of casing terminated aVor below land surface may require
a vanance in accordance with 15A NCAC 2C 0118. l
e. YIELD (gpm): (LJ 0 METHOD OF TEST 1 / l
f. DISINFECTION: Type \ (/ C U 0 Amount
g. WATER
(depth).
From
D z fad tieom
Z
From �o 5� ( from
To
��pp To
From (P 56To (6560 1'F o t To
6. CASING:
Depth Diameter
From To Li (')Ft
From To Ft.
From To Ft
7. GROUT: Depth
Matenal From, To u C)Ft. IO(J+
From To Ft. J
Thickness/
Weight Matenal
Method
From To Ft.
8. 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
From To Ft
From s To Ft,
From - To Ft.
10. DRILLING LOG
From To Fo •tion '-scnption
11. REMARKS:
�� 6 VW
1v�P�
IDOHE
15A N
RECOR
SIGN URE OF C RTIFIED WELL CONTRACTOR DATE
a�)'Si�v1s
PRI pc
NAME OF PERSON CONSTRUCTING THE WELL
t.�
1nio"'abovvku w
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
UCT10N STANDARDS, AND THAT A COPY OF THIS
DT0 THE WELL OWNER
Y CERTIFY
C, WEL CONS
S aE�E ROVI
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center— Raleigh, NC 27699-1817 Phone No. [phone] ext 568.
Form GW-lb
Rev 7/05