389832_Well Construction - GW1_20101202

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Frn ironment and Natural Resources- Division of Water Quakily
WELL CONTRACTOR CERTIFICATION # 3424-A
1 WELL. CONTRACTOR:
Michael S. McClure
Well Contractor (individual) Name
Tarheel Water Treatment, Inc
Well Contractor Company Name
3494 Georgia Road
Street Address
Franklin NC 28734
City or Town State Zip Code
(828 ) 369-0740
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# W 10400133
OTHER ASSOCIATED PERM(T# if applicable)
SITE WELL ID #(if applicable) 3,,S
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public E
Industrial/Commercial ❑ Agnculturai ❑ Recovery 0 Injection
Irngation❑ Other ❑ (list use)
DATE DRILLED I V
4. WELL LOCATION.
1735 Saxaoahaw-Bethleham Church Road
(Street Name, Numbers, Community Subdivision Lot No , Parcel Zip Code)
CITY Saxaoahaw COUNTY Alamance
TOPOGRAPHIC / LAND SETTING (check appropriate box)
r1Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36 ° " DMS OR 3x xxxxxxxxx DD
LONGITUDE 75 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source BPS Qtopographic map
(location of well must be shown on a USGS topo map andattached to
this fonn ,f not using GPS)
5 FACILITY (Name of the business where the wet Is located )
_,Saxanahaw Rjverlvhul Rends
Facility Name Factirty ID# (if applicable)
1735 Saxaoahaw-Bethleham Church Road
Street Address
Saxaoahaw NC 27340
City or Town State Zip Code
John Jordan
Contact Name
P_C) Rox 128
Mailing Address
Saxaoahaw NC 27430
City or Town State Zip Code
t >
Area code Phone number
6. WELL DETAILS.215/0
/
a. TOTAL DEPTH
b DOES WELL REPLACE EXISTING WELL? YES
NO Gil
c WATER LEVEL Below Top of Casing ,z! 1 FT
(Use "+" rf Above Top of Casing)
d. TOP OF CASING IS 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) 5` METHOD OF TEST
C
f DISINFECTION Type Or, Amount
g WATER ZONES (depth)
Top I--100 Bottom Top Bottom
Top Bottom Top Bottom
Top_ Bottom Top Bottom
Thickness/
7 CASING. Dept Diameter Weight Material
Top Bottom
Top Bottom
Top
8 GROUT Depth
Top Bottom Ft
Top Bottom Ft
Tap Bottom Ft
Material
9 SCREEN Depth Diameter
Top Bottom Ft In
Top Bottom Ft in
Top Bottom Ft
10 SAND/GRAVEL PACK
Depth
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
4/,
Method
Slot Size Material
In
in
in in
Size Material
Formation Descnption
t**" Ate.
12 REMARKS
Geothermal Use On!
I DO HEREBY CE,1?,TIFY
15A NCA WELL
RECO BEEN
DECQ -r'
inn 2 20 0
orrnabon Pro °,,QeSS,,
uQ s Drift
URE OF CERTIFI D WEL
NTRACTOR
Michael S. McClure
PRINTED NAME OF PERSON CONSTRUCTING
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
UCTED IN ACCORDANCE WITH
AND THAT A COPY OF THIS
ER
R /C'77./?
DATE
PEC 1 8 2012Formw-1b
Rev 2/09