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. [phone] ext 568.
Form GW-lb
Rev. 7/05