388639_Well Construction - GW1_20101102

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # l S-1 5
1. WEL - ONTRACTQR:
t tG V`'\ b rS
Well Contract (Individual) N
l 1 r() S
Welt actor Company me 6 ( rz)a
STRTREETET -17
ADDRESS
`
C/a,( n C /uC
' City or Town State
(s-M)- 36at -1 SOCIO
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(Aapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring t 1uiiicipaUPublic 0
Industnal/Commercial 0 Agricultural 0 Recovery 0 Injection 0 9
Irrigation❑ Other ❑ (list use) Tap- oeK4fL1(�u& /
DATE DRILLED I �'� - J
TIME COMPLETE^ (j�s
3. WELL LOCA T+ON:
CITY (6 e
cc©D
Zip Code
AM ❑PM Lr
UNTY ► ULC�jC
(Street Name,umbers, Community, Subdivision, Lof No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley, 'Fiat oRidge 0 Other
(check appropriate box)
LATITUDE 3 l U 0 `1,-/
LONGITUDE _d S� • Cl�i
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: S ❑Topographic map
(location of well must be shown on a USGS fopo map and
attached to this form if not using GPS)
4. FACILITY. Is the name of the business whe thew 'hatted
FACILITY ID Cif applicable) I
NAME OF FACILITY
cc caw,
STREET ADDR S p& O L)` O Li�n CYv iQ f /" , -
ityorTown IA
ZipC e
CONTACT PERSON VIA t c �i 561"
MAIL ADD ES 1-454)L) cr0 U 171 VC)
City o7� � State Zip Code
CloL
(pb7)
Area code - Phone number
5. WELL DETAILS: a. TOTAL DEPTH: D-5
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO,Er-
c. WATER LEVEL Below Top of Casing. /07/7 FT.
(Use "+- if Above Top of Casing)
j A)
tr +,4 e
d. TOP OF CASING IS /V/i - FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm): / v7A METHOD OF TEST
f. DISINFECTION: Type /)l7/4 Amount
g. WATER 20NF8 (depth)
From ___ From
From To From
From To From To
To
To
6. CASING: Thickness/
Depth Diameter Weight plyncal
From „CO To ( Ft
From To Ft.
From To Ft
7. GROUT:
Depth
Matenal Method
Fromo Ft
From To Ft
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
o -`
From J To %-0 Ft. 1 in. in. , Per�
C
From To Ft. in. in.
From To Ft. In. in.
9. SAND/GRAVEL PACK:
Dep Size Material
From l/ 7/61 Ft
From To Ft.
From To Ft,
10. DRILLING LOG
From To v— rU F rmation Description
2qtb--aS 5, e ton
e
Rg9 1Y e•-s. fie.°
an
Nmi 0 LU 1�
',-itarmation r'roct ya...y
DW
11. REMARKS:
IDO
15A
R
EBY CERTIFY THAT THIS
2C, WELL C((?�IlSTRUCTI
tHAS BEEN Pg'oVIDED TO
ELL WAS CONSTRUCTED IN ACCORDANCE WITH
STANDARDS, AND THAT A COPY OF THIS
E WELL OWNER,
SIG URE OF CERT FIED WELL CONTRACTOR
SIG
a U t 5(��-0 K\
PR TED 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 27699-1617 Phone No. [phone] eat 568.
Form GW-lb
Rev. 7/05