380083_Well Construction - GW1_20100106

WELL CONSTRUCTION RECORD
Ia,dols4C.
38008
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) EA- -en_ e.. 1 71.0 ei CERTIFICATION #1/Z /
WELL CONTRACTOR COMPANY NAMECfhP // �/'��� //PHONE#t76 % 2r.3 Too 7
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# /4 /
/2Pt. C�awA...fY 09—/67
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential in--Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection ❑ Other ❑ If Other, List Use
2. WELL LOCATIO // //
Nearest Town: oh ro e, County /(Ail
�F/‘ /A.'3/cI.e/ 61'oona. e £cL
(Street Name. Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: De nee -I /ye,bn..,y- G'ohsfiaC,"�io^.
Address / Slat, f 4j, ,- ,S% 7L CeA.i lcc '
(Street or Route No.)
/VC
Z6?// Z
City or Town State Zip Code
7Q4 )-5c7*S89z
4.
5.
6.
7.
Area code- Phone number
DATE DRILLED //— 57- 0 9
TOTAL DEPTH:
DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ek
STATIC WATER LEVEL Below Top of Casing: Z S FT.
(Use "+" if Above Top of Casing)
8. TOP OF CASING IS / FT. Above Land Surface*
*Top of casing terminated at/or below land surface requires a
variance in accordance ith ISA NCAC 2C .0118. i
9. YIELD (gpm):. /72 METHOD OF TEST/9'
1.
10. WATER ZONES (depth): G Y / — //z (1' pin
11. DISINFECTION: Type ///T/7R
Amount 20 62,
12. CASING: Wall Thickness
Depth DiarReter . or Weight/Ft. Material
From — / To 39 Ft.I)R-a Pv G
From To Ft.
From To Ft.
13. GROUT: Depth Material 11 ethod
From 0 To 3SFt. ,3e,A'7fn+r;-k. U-+wp
From To Ft.
14. SCREEN: Depth Diameter Slot Size Material
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topographic/Land setting
DRidge 1 3T pe ❑Valley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DRILLING LOG
Formation Description
Re-4 C,/r y
So�f taro Non CI a y f 2oG4 .
DEPTH
From To
0 2 1
/.S' 7 Se,-
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common road names.
'JE D
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELL .iAN 0 6 2010
CONSTRUCTIQ1 STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�— Infmat•io r Procassing Unit
o—O / / - VC.i/BO 3
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center - Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 07/2001