389682_Well Construction - GW1_20101201

1. WELL CONTRACTOR:
.NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
Well Contractor (Individual) Name
Well Contractor Compapy Name
10 ma(st, t=l e1ck br
Street Address
Foci- tIh 1 i
City or Town
(g03) .5y?-mi1€O
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
c-• �- c.`i 7O7
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring Wf Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED /B '6'iU
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, Lot , Parcel, Zip Code)
CITY: J ``-1( LLJ COUNTY i.i i'1 tO V
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE " DMS OR DD
LONGITUDE' " DMS OR DD
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
c"5-1-6(x1 Cite
Facility Name
Street Addres
UA.) CA.)( c )
F cility ID#9,f applicable)
1Ihy
City or Town State
MO t e. (e+ et1CSS
Contact Name
bO8 C,r.t vv.e-k r rive;S`4 0
Mailing Address
ynotrrIS011€
City or Town
Zip Code
(citC%) Hbl - 1423
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: P
L. <9-1560
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO.2°-
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if 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):
METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top () Bottom Ig Ft. ( PV L
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 1 e Bottom Ft. ILL. in. --01O in. s ..d •
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom 16
Size
Ft. -EQ__
Top Bottom Ft.
Top Bottom Ft.
Material
11. DRILLING LOG
Top Bottom Formation Description
/
/
/
/
/
12. REMARKS:
B/. w 66 - 4.
61i II-14
ucl., 01 2010
,,nr:ie tion Processing tiff.
DWQ/BOG
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 HA , BEEN PROVIDED PO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09