386263_Well Construction - GW1_20100813

WELL CONSTRUCTION RECORD
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366263
North Carolina - Department of Environment and Natural Resources - Division of Water Quality - Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME riot) of ,Q/e r�/�, (� es
WELL CONTRACTOR COMPANY NAME ( he..- (/v✓ e_. 1
STATE WELL CONSTRUCTION PERMIT#
(if applicable)
CERTIFICATION # (a Z(
',//PHONE #2OTI �j-4667
ASSOCIATED WQ PERMIT#(.49Cbbt C6 t �y - / 14.
(if applicable)
1. WELL USE (Check Applicable Box): Residential Municipal/Public 0 Industrial 0 Agricultural 0
Monitoring 0 Recovery 0 Heat Pump Water Injection 0 Other 0 If Other, List Use
2. WELL LOCATIO
Nearest Town: / 17( Kt" 6*-,
5-3 1 bl�l
53d% .5-c Kc .
(Street Name, Numbers, Community, Subdivision, Lot No., Zip Code)
3. OWNER: Ge.Vea.lC // 1 s
Address 5-3 07 VI:L k J.
Al(Street. or Route No.)
anrec C 2-8I1 Z
City or Town State Zip Code
� t$ )- Z 17 -* 773-Z
Area code- Phone number
4. DATE DRILLED e -/
5. TOTAL DEPTH: / d ti
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO
7. STATIC WATER LEVEL Below Top of Casing: Z? 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): 2,0 THQD OF TEST .41:/"
10. WATER ZONES (depth): Z. — Z o jen•k
11. DISINFECTION: Type /47/I
12. CASING:
Depth Di meter
From — / To 5_ 0 Ft.(.0
From To Ft.
From To Ft.
13. GROUT: Depth
From V To 3.r
From To
14. SCREEN: Depth
From To
From To
Amount T O'Z
Wall Thickness
or Weight/Ft. Material
a2 -Z,1 Pi/ c•-
Mat rial ethod
Ft. �Cti�t►)1 Ft.
Diameter Slot Size Material
Ft. in. in.
Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From To Ft.
From To Ft.
16. REMARKS:
Topoggrap c/Land setting
❑Ridge ope ❑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 For ation escrtption
S'
7,9
4'a
6 S _� �r YrwlLS�C,t,
Fhk e_d 8✓ " W
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Includerthe road
numbers and common road names. �.
K°S
RECEIVED
G 1 3 2010
cessing Unit
G
Information
yvQ1B
I 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
ti
SI N� ATURE 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