388640_Well Construction - GW1_20101102

NONRESIDENTIAL WELL CONSTRUCTION RECORD Q
North Carolina Department of Environment and Natural Resources- Division of Water Quality `-
WELL CONTRACTOR CERTIFICATION # J l 1 5
1. WE ONTRACT R:
a��rc�S I�►�aik-S
Well Contract (individual) N e
Pi al nnd�
Well Contractor Company
Nam-e7 j� /
STREET ADDRESS Co 1 CJ V
(/ P A)(
City or Town State Zip Code
f�7d-1)- I Co
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(Rapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring 0 Mu icipaUPubtic 0
Industnal/Commerciai ❑ Agricultural 0 Recovery 0 Injection 0 l 1
lrngation❑ Other ❑ (list use) I-er-N0eYAI (.�t.)2
DATE DRILLED 1 �' J
TIME COMPLETE _ Ph
3. WELL LOC'�AT,�IO,N:_ -,
CITY* c /L (G fro
AM ❑ PM-
NT�Y
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code}
TOPOGRAPHIC / LAND SETTING'
❑Slope ❑Valley ,'Flat ❑Ridge 0 Other
(check appropriate box)
LATITUDE 3
LONGITUDE U 5)•CO3
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ,4GPS ❑Topographic map
(location of well must be shown on a USGS fopo map and
T attached to this form if not using GPS)
4. FACILITY -is the name of the business whe
FACILITY ID #(if applicable)
NAME OF FACILITY
'STREET UO
E ADDR S
ity or Town //��Stat
7
the w - i;,ocated
,ct
ra
CU
CONTACT PERSON rim £ 6
MAIL ADDI,ES,t � � _So c.)
City a T rLLLL// State
Zip Cotcle
56
t )
egg, qcOc-erO7
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: D-5
Zip Code
UI
b. DOES WELL REPLACE EXISTING WELL? YEppS��❑ NOAr
c. WATER LEVEL Below Top of Casing. /17 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS ./VA. FT Above Land Surface*
`Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118.
e. YIELD (gpm): / v7A METHOD OF TEST
f. DISINFECTION: Type /1//!- Amount 4/�f4
g. WATER ZONF8 (depth).
To
From
From
From To
From To
From To From To
6. CASING:
Thickness/
Depth Diameter Weight atenat
From 4.O To (`) Ft. l (i (
From To - Ft.
From To Ft
7. GROUT:
/ Depth
From / ,/, o Ft
From To Ft
From To Ft.
8. SCREEN: Depth Diameter
From a J To )--0 Ft 1 in.
From To Ft. in.
From To Ft. _ in,
9. SAND/GRAVEL PACK:
Frorn Ft
From «< To Ft.
From To Ft.
Material Method
10. DRILLING LOG
From To
6 -- / U
rc��aS
11. REMARKS:
Slot Size Material
In er
in.
In.
Size Material
Fgrmation Descnption
SI4
r-- s q sea
E.'L.., ; a \a raj
NUV If LGlu
InfOtinauuin rtu4tisstng unit
I DO EBY CERTIFY THAT THIS ELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A 2C, WELL CSTRUCTI STANDARDS, AND THAT A COPY OF THIS
RE RD HAS BEEN PFtmVIDEO TO E WELL OWNER
SIG URE OF CERT FIED WELL CONTRACTOR DATE
of u t C'� 5rf� S
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] ext 568.
Form GW-lb
Rev. 7/05