386557_Well Construction - GW1_20100901

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
5" 5 7
1. WELL CONTRACTOR:
Xe-..t.)//1 /►).•%•
Well Contractor (Individual) Name
,m c f / 6/b'S
STREET ADDRESS ZOO Ar.orSc= 41,1
C lam/'% fe-- AvG /
City or Town State Zip Code
(°1(>-.?4c
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(it applicable)
Well Contractor Company Name
STATE WELL PERMIT#(dapplicable) / 2. 7013_0
DWQ or OTHER PERMIT #(if applicable) 70 0 0/ 7q
WELL USE (Check Applicable Box) Monitonng MunicipaliPublic ❑
Industnat/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED"
TIME COMPLETED
3. WELL LOCATION:
CITY Gl,-,,r/o,k—ee
AM❑ PM❑
COUNTY /7 GG/(
(Street Name, Numbers, Community, Subdivision, Lot No„ Parcel, Zip Coda)
TOPOGRAPHIC / LA1�-;:f TING.
❑Slope ❑Valley Fiat ❑Ridge 0 Other
(check appropnate box) LATITUDE 3 12 q 71
LONGITUDEO f0 t%t 23 e
May be in degrees,
minutes, seconds or
m a decimal format
Latitude/longitude source: PS ❑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 applIca Ie)
NAME OF FACILITY V(;jL 7(chip5O
STREET ADDRESS R7 7411 S 7
r/OAP i/11C�
City or Town Sta e
(7°Y )-s413z-- Z7��
Area code - Phone number
8. WELL DETAILS: q
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 1pf
c. WATER LEVEL Below Top of Casing T' v FT.
(Use "+" if Above Top of Casing)
City or Town StateZip Code
CONTACT PERSON fiiil d ahe/'1 h!
MAILING ADDRESS 99 /dl PsrX /"r/ C'.o (,2,
.7 Sd'ZO
Zip Code
d. TOP OF CASING IS 2� 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)• / METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (dept)
From/To3 6 From To
From To From To
From To From To'
6. CASING:
DepthDiameter
From Q To / r Ft
From To Ft.
From To Ft
7. GROUT: Depth
From To Ft
From To Ft
From To Ft.
Thickness/
Weight Matenal
Matenal Method
8. SCREEN: Depth Diameter Slat Size Material
From.; 5 To / 5 Ft in.
From To Ft. in.
From To Ft.in.
9. SAND/GRAVEL PACK:
Depth
From To Ft.
From To Ft.
From To Ft.
10. DRILLING LOG
From ` Ip
to
tn.
In.
Size Matenal
43Formation es ption
't.G/G� //
2/11—i C Je-.4
eff C/t
y
sel/3
r •-• SIG H
RELRLI Rq
SE? x Lulu
Informasiarr r ors
^
11. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WRH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOj O HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
r
f (&.J 1`r p)ori—i�
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 27699-1817 Phone No. [phone] ext 568,
Form GW-lb
Rev 7/05

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