388643_Well Construction - GW1_20101102

NON ONRESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # - S onl 5
1.WE
ONTRACT R:
()turd t�'''li'Ltb1�S
Well Contact (Indwidual) N e
r at l I») fif
Well Contractor Company
DRame7 j� / -
STREET ADDRESS l� ((J V ( r Imo. h�
DR ,> T P /Le
Zip Code
City or Town State
(7d-1)- CICt -1 S Co
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
STATE WELL PERMIT#(irapplicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring 0 MubicipaUPublic 0
IndustnaVCommercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use) (r-N0YAr(..3 we / 7
t c'
DATE DRILLED I L>'_ 1 - lb
TIME COMPLETED 3-:6O) AM ❑ PM 41-
3. WELL LOCATION
CITY• C -1/�.2 II OU) TY ► UL�,�
SSW
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley .@'Flat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3 �_ 4
LONGITUDE 1LU 52•(03
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 or the business who : thew ig jocated
FACILITY ID *Of applicable) V„�
NAME OF FACILITY
STREET ADORES,/L> c u
1 �
City or Town Stall Zip Coye
CONTACT PERSON P+' �U ( Cif Y'l6' LSAT C)56i"
IL G AD MAD7ES (--1 C)t) 'C) C. llI i iC)
Zip Code
c( "'',)CIT 0-1SSb?3
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 5
b. DOES WELL REPLACE EXISTING WELL?//YES 0 NO,r
c. WATER LEVEL Below Top of Casing. /�7 ppFT.
(Use "+• if Above Top of Casing)
9 r,r #e
0 _I 411
d. TOP OF CASING IS / v/%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): / v/A METHOD OF TEST fIA/71
f. DISINFECTION: Type 4/7-!- Amount 447/-
i
g. WATER ZON (depth)
From A From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Matenal
From , ) To h Ft ( j
From To Ft.
From To Ft
7. GROUT: Depth Matenal
From /A° Ft
From To Ft.
From To Ft.
Method
8. SCREEN: Depth Diameter Slot Size Material
J From ' To a) Ft. 1 in. In A/C
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Dep Size Material
From A li Ft
From To Ft.
From To Ft.
10. DRILLING LOG
From To F9rmation Descnption
6-- r0
� i� V „ g,- ;;, \ I C,- C
11. REMARKS:
Nnv n 2 /UIU
Informatia'i Vi.oi...essing Unit
UW(d/t3ULa
IDO
15A
R
EBY CERTIFY THAT THIS ELL WAS CONSTRUCTED IN ACCORDANCE WRH
2C, WELL CQQtjJJSTRUCTI STANDARDS, AND THAT A COPY OF THIS
RO\IiAS BEEN PVIDEO TO E WELL OWNER
SIG URE OF CERTIFIED WELL CONTRACTOR DATE
0OAU tcj 5(/)1S
PR TED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-lb
Rev. 7/05