382672_Well Construction - GW1_20100421

11L�SJDENTl_�L W>:LL COMTRUCT1ON )TCCORD
Nunn Carolina Department of Environment uno Natural Resources- DiviS.k of WAIN' Quality
WELL CONTRACTQR CERTIFICATlON.tr Z319
N(a 1 at 2-6]c-A C.
33 672
1. WELL. CONTRACTOR:
GSA e-L.1 C
ail C ntrs:tlr (Inkivµlu
ame
lull) Cams: tar camp--NNsmo' t
STR ET .A RtS3 L , 0 , (�%5%. Z9a.
,�. ,!/, c., a. 9 697
g of Town Stsde Zip Coda
Area .aa< Pnana numadr
2. WELL INFORh TION:
S IT E tV ELL to Bar =pptieinle) D / - - 47,6
STATE WELL PERMITatu applicaota)
DWQ OThER PERMIT *(if appliestile)
W Etj, U_E (CnetiK i pticiole Box): R iperuial Wader Suppl
DATE DRILLED - 2-3 - % 0
TILE COMPLETED J e 0 O
3. WELL Ly�
O�CATION:
CITY: 1 I{ 1 't l e'C-t4/ 5 COvN/TY (milf
tire)00: d
,-r(ax c.,4 40 ,35/
iStii.ct Name, Nurrocrs. Canmuriuy, Suonivision, 40l No_ Parcta, Zip Coda) -
TOPOGRAPhIC 1 LAND SETTING:
C Stopd Q'i;ircY f'— Ridgs ❑Qthcr
ter esx :,ppropnak Dolt
LATITUDE 3 s
.
LONGITUDE. 8 et1, % 3
L,:riruJe!Wn4,irude source: [GPS ' ❑Topographic map
tocar;an or well must se, snown an a USGS lop° map 8rttl
+nacnaa to tn;r form ii not using GPS)
�. Wc".LL OWNER
OWHER'S NAME (},t+4 84-1-ci'e(s�
STREET nOORESS i O (1 C-3.. 14,1•42
r
C . 'S 0-©
City or Imn State lip Coda
7z.. t -• t 3(
Area co.1e - Phone numoer
AM [) PM
May be in dcgrecs,
minutes, Scconos Dr
in a decimal format
5. WELL DETAILS:
TOTAL DEPTH:
00
D. DOES WELL REPLACE EXISTING WELL? YES ❑ NO tr—
c. WATER LEVEL Below Top of Casing: 4/3 FT.
(Via't if Above Top or Casing)
/
Q. TOP QF CASING IS % FT. Above L4n4 Surjaj2'
'Top o1 c irri terminmi4 IUD( ltzlaw I'no Surface may require
a ``"riani.a in 9Ccp(d+ncs with 16A Ne_AC 2C _0119.
YIELD
c. (gprny / taETt1OD OF TEST /7 //2---
t. DISINFECTION: Type - :l' Amount
9. WATER ZONES (neprn)-
_.From.e/1A/rhr-
From TD
From To
6.
CASING:Deh
From ( _ ToI(4-Q FL
From
To FL
parryklar
('!
from To Ft.
7. GROVT:nnDepth
From v To,
From To
From Te
From TO
From To
From To
Thickness)
1Nai hl M re iar
au:trial
FL /G' �i
L)/z'.%v t Yam{
Ft.
FL
Mothod
r;1
a•
8. SCREEN: Depth Diamo►ar SIOt $)xa Malarial
From _ To _ FL in. In.
From • To Ft. in. In.
From To _ FL _-In.
9. SANWGRAVEL PACK;
Depth
from To F[
From To FL
Sizes Matettal
Frpt[r To FL
1Q. DRILLING LOG
From To
v
Formation OeSociptran
!d'%f?Jl1 .41 C
lit
/ -U - 6 0 6' 0- a r23 s 1 t t
1. RE1 tA.RKS:
tA) cts cLA
dJV 't [[7V cQ IPV koS'!
100 HEREBY cER1ifl Trig THIS WELL WAS COA1131,1CTED IN ACC I/ma Wrl}I
15A C, WELL CONSTRUCTION STAHOARPS, ANP1114 A GQri RF Tiil9
%-
RECO hAS SEEN PRQVIDEDTO THE WELL OWN6R.
OfCrNtr-nn pry
If 1L.., JL V
APR- 2 1 Z[Jlu
rrocessinn I trs;*
- ,✓vvL.UtSOG
/SIGNATURE
f �l- L C*.
PRINTED NAM QF PERSON CONST UCTINGT)1E WELL
.2`25 10
WELL bNTRACTO(2 DATE
Submit tfIE original to the QLVISIQf1 of Water Quality within 30 days. Attu: Information Mgt.,
1617 14U-11 S rvics Center-- Raleigh KG 27699-1617 Phone No. (419i 733401 e•xI 66B.
Form GW•1a
Roy. 71Q5