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388642_Well Construction - GW1_20101102
NON ONRESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # J <5 1 5 1. WE ONTRACT R: )&S Well Contractor Company Well Contract (Individual) N e l I )17) STREET ADDRESS amem-7Gq.:(2)1.4.4 1 6, (; P /L( City or Town Stale (�7 )L-lr �1� I LCo Area code- Phone number 2. WELL INFORMATION: SITE WELL ID #(if applicable) STATE WELL PERMIT#(dapplicable) DWQ or OTHER PERMIT #(if applicable) WELL USE (Check Applicable Box) Monitonng 0 Mufricipal/Pubtic ❑ Industnat/Commercial 0 Agncuitural 0 Recovery 0 Injection ❑ 1 trngation❑ Other ❑ (list use) Tyr-t0e-Yaf9 / / DATE DRILLED 1 ©� 1 - ( , TIME COMPLETED d'Ai -Y J6 AM ❑ PMe( 3. WELL LOCCAT'ION: I /� ,, CITY C�V�-c��{ (C) C�Ut�TY I eCA.'! Zip Code (Street Name, Numbers, Community, Subdivision, Lot No , Parcel. Zip Code) TOPOGRAPHIC / LAND SETTING. ❑Slope ❑Valley .@'Flat ()Ridge 0 Other (check appropriate box) LATITUDE 3 6I0 lCL LONGITUDE _LC) ).,2 • CO-S May be in degrees, minutes, seconds or in a decimal format Latitude/longitude source: GPS ❑Topographic map (location of well must be shown on a USGS topo map and attached to this form if not using GPS) 4. FACILITY -is the name of the business whe : thew i; jocated FACILITY ID #(if applicable) �� NAME OF FACILITY ,ct STREET ADDRET - l,� U cu City L,, ) ojiT0� Area code- Phone number 5. WELL DETAILS: a. TOTAL DEPTH: D-5 City or Town n Stat Zip Code y� CONTACT PERSON ' � cl 6 6 LsAi561" MAILF ADD ES Uc� SO C� 1 l )0J State Zip Code b. DOES WELL REPLACE EXISTING WELL?t YES ❑ NQ�' c. WATER LEVEL Below Top of Casing. /t-'7/7 FT. (Use "+" if Above Top of Casing) 3 l 'it2 d. TOP OF CASING IS .47/4 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). / v7/4 METHOD OF TEST Vid f. DISINFECTION: Type 4l/f Amount /1/ZA g. WATER 1—�— (depth) From 4- From To From To From To From To From To 6. CASING: Thickness/ Depth Diameter Weight atenal From ,;2C� To C) Ft ( V(/ From To Ft. From To Ft 7. GROUT: Depth Matenal Method From //Ao Ft. From To Ft. From To Ft. 8. SCREEN: Depth Diameter Slot Size Material From a `J �L To )-0 Ft � in. in /Cer, From To Ft. in. in. From To Ft. in, in. 9. SAND/GRAVEL PACK: Dep j Size Material Fromi/ Ft From To Ft. From To Ft. 10. DRILLING LOG From To U c."_tF4rmation Description 11. REMARKS: l r"p V 'lam NIJV if Z LU10 InTormanors i-,acessing unit l' V V IL., DO EBY CERTIFY THAT THIS 15A 2C. WELL CQQ1(J1STRUCTI RE RO HAS BEEN PVIDEO TO ELL WAS CONSTRUCTED IN ACCORDANCE WITH STANDARDS, AND THAT A COPY OF THIS E WELL OWNER SIG URE OF CERT FIED WELL CONTRACTOR DATE 0PAu tc�6' 5(� Is PRINTED 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. (919) 733-7015 ext 568. Form GW-lb Rev. 7/05