383836_Well Construction - GW1_20100428

Attl);)Ackl.
WELL CONSTRUCTION RECORD
WELL CONTRACTOR (INDIVIDUAL) NAME (print) ERje,n.e, aid e-
e2iVZ Aje// Or:1/;►t3
STATE \\'ELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT# UJ'I h iti�/Q ^33
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Sect3
ion'' 0(../
CERTIFICATION #2"/11
WELL CONTRACTOR COMPANY NAME
(if applicable)
(if applicable)
PHONE VO Y ) 2,1"3 6r3
1. WELL USE (Check Applicable Box): Residential lEr-c1unicipal/Public ❑ Industrial ❑ Agricultural ❑
Monitoring ❑ Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO_I4:
Nearest Town: 6HYo e-,
vv�►`1"
��i//2 ecs.
County (/t H
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER:Xdfs-dlj's CIA-Sc Nprke
Address l.?/e //e / S 5-CI. 1t %Zvi
%'/Qh ✓0 a ,, (Street Route No.) C F//
Coy or Town State Zip Code
('O9)- OW — 2V/
Area code- Phone number
4. DATE DRILLED Ill- 7-/6
5. TOTAL DEPTH: 265"
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NOstr
7. STATIC WATER LEVEL Below Top of Casing: 36 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 15A NCAC 2C .0118.
9. YIELD (gpm): 3 METHOD OF TEST/7»'
10. WATER ZONES (depth): O ' /%Z, C/ '1
/ fr2 6'Pr7
11. DISINFECTION: Type Al 7/ Amount 4 Z
12. CASING: Wall Thickness
Depth Diameter or Weight/Ft. Material
From / To Vb Ft.6frg DR- Z/ Pit
From To Ft.
From To Ft.
13. GROUT: Depth Material , // Method
From 0 To ' S Ft. Be.n'1-4,A i`tc_ /�i..- Ai'
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 IKISI pe ❑Valley ❑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, pR'escrl tion
)e/lac, C-Ick-
4�' /F!StouG
2_65— ' S/w G S/ci.. e.
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.
(1
;
14 Ir
RECEIVED
MAY 2 8 2010
Information Processing Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH I5A NCAC 2C, WELLDWQ/BOG
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
c ' Cot' 174 _ F -/ 0
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