383838_Well Construction - GW1_20100428

WELL CONSTRUCTION RECORD
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) eC Etc) v o2 CERTIFICATION #2-1Z-/
%YELL CONTRACTOR COMPANY NAME 60./0,:- 1"-1-/1 0r. 1/, h51 PHONE it e/ `,4
,L2. 2- ✓7 -�'6O
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT#An t �n etih.d / /O -73
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public ❑ Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other ❑ If Other, List Use
2. WELL LOCATION:
Nearest Town: AIOPt✓ oe
33 /', Wog' f?•
County LL 1. t
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:R[Cit /-4.1... ie y
Address 2?y--5! ga /1 , /-J /ts Dr.
/y� (Street or Route No.)
/'l is h r o e. /U C. CT / II
City or Town State Zip Code
76 0)- zr d ci /-7
Area code- Phone numbe
4. DATE DRILLED /3
5. TOTAL DEPTH: ' r1 3,S-r
6. DOES WELL REPLACE EXISTING WELL? YES&<O ❑
7. STATIC WATER LEVEL Below Top of Casing: 3'Zi 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 with I5A NCAC 2C .0118.
9. YIELD (gpm): 2 O METHOD OF TEST/� 't'
10. WATER ZONES (depth): 83 — / G' PM
? `- / 6'P:n
11. DISINFECTION: Type /47 // Amount /0 62.-,
12. CASING: Wall Thickness
Depth tameter or Weight/Ft. Material
From / To . % Ft.( OR-z� Pt/ G
From To Ft.
From To Ft.
13. GROUT:
From c
From
14. SCREEN:
Depth _ Material Method
To 'S .) Ft. Pehj.6n 1+ - riA-44-L
To Ft.
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.
I6. REMARKS:
38
Topographic/Land setting
DRidge 8e DValley ❑Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source:❑GPS❑Topographic map
(check box)
DEPTH DRILLING LOG
From To Formation Description
ed C/0-� P
D // '
/1' /9 `
/9' 43 - -
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.
•r,
RECEIVED
MAY 2 8 2010
Information Processing Unit
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
CaX
SIGNATURE OF PERSON CONSTRUCTING THE WELL DATE
-/6
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
u