386558_Well Construction - GW1_20100901

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NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Ji0.0/r7 /Y)orri5-
Well Contractor (individual) Name
/y'I Gc GI /35`05/
Wet Contractor Company Name
STREET ADDRESS i �4:1° PitiM5%/L06lvci
C4sflo f,Pc_ rvL 2$21 L.
City or Town State Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(rf applicable) 1 27 `"d%3'-0.3
DWQ or OTHER PERMIT #(if applicable) 7'4'/ % y
WELL USE (Check Applicable Box) Monitonng IfMunicipai/Public ❑
Industnal/Commerclat ❑ Agricultural 0
trngationo Other
0 (list use)
DATE DRILLED D 3 —
Recovery 0 Injection ❑
TIME COMPLETED AM 0 PM 0
3. WELL LOCATION:
CITY Ci h cNr/0744'e COUNTY 6.6K
9 fit sf 2g a
(Street Name, Numbers, Community, Subdi ision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley jeFlat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3 , 12 p I I t
LONGITUDE O_ y 1 -Y9
Latitude/longitude source: t rPS ❑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 where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY i" it'L Th -skiff)
� STREET ADDRESS ' `1 .5-7
May be in degrees,
minutes, seconds or
in a decimal format
C h c,ri /✓C, 9 in 0 g
City or Town State // Zip Code
CONTACT PERSON Ad rh a1 p
MAILING ADDRESS d I / 1 /"ary(r,cot T 5C-112-
City or Town State Zip Code
(7O )- g' z- 271V
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 3 t
b. DOES WELL REPLACE EXISTING WELL? YES ❑ _ NO /
c. WATER LEVEL Below Top of Casing: / v FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 4v 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). r METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth)
From„W To.3 From To
From To From To
From To From PTO
6. CASING: Thickness/
Depth Dtan)e)er Weight Matenal
From V To/0 Ft i
From To Ft.
From To Ft
7. GROUT: Depth
Matenal
From To Ft.
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter
From /0 TQ30 Ft. / ,�n.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
Method
Slot Size Material
In
in.
in.
Size Matenal
From To Ft.
10. DRILLING LOG
rom Toa
y /
�'� 9y
11. REMARKS:
Forma •n �escnption
C. ,/
wn
; 111/0—n
SFP 1 — 7nin
Information Proceccin„
uWQ/BOG
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD.HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Ke,u)fA (Y)o r-T-15
PRINTED 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 668.
Form GW-lb
Rev 7/05