394445_Well Construction - GW1_20110602

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NON ONRESIDENTI L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # o(Z
1. WELL CONTRACTOR:
< r\OvYlo Gr, S`9-74--/
We
ll Contractor (Individual) Name
Well Contractor Compan Name �j
STREET ADDRESS 62) / ks1•t ,v' _rj-(� 1'-
C c,r"f><e ,f,c
City or Town State
( 7C-( )- 3'7? So 6
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) /11/
STATE WELL PERMIT#(iif applicable) ' i - 52.
DWQ or OTHER PERMIT #(if applicable) /V/ Pi
WELL USE (Check Applicable Box) Monitoring 0 MunicipaUPublic 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
IrrigationEr ether ❑ (list use)
DATE DRILLED (-{2_ -t )
TIME COMPLETED S , VI) AM 0 PM Io
3. WELL LOCATION:
CITY: IA/ N4 1/1Pn tA% COUNTY
Zip Code
Mtnr(), i
Soto a -fox /C2073
(Street Nam:', Xnbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ['Flat DRidge 0 Other
(check appropriate box) ._
LATITUDE 3 S 00 , SS r May be in degrees,
minutes, seconds or
LONGITUDE le, (0 in a decimal format
Latitude/longitude source: m•GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY. Is the name of the business where the well is located.
FACILITY ID #(if applicable)
' NAME OF FACILITY•
/
STREET ADDRESS
City or Town State Zip Code
CONTACT PERSON CtVt+0SieN CAVA Ii
MAILING ADDRESS Sa 0 A dwta4oh OP.
`A/i nr. v Pi- k —2$ I 11
City or Town State Zip Code
(7 (2 LI. )-q 2) c q 6
Area code - Phone number
5. WELL DETAILS: r1
a. TOTAL DEPTH: �7 J9 O
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO RV
c. WATER LEVEL Below Top of Casing: ) 5 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS • 5 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):1 2. METHOD OF TEST I3 jn LJ
f. DISINFECTION: Type C\-.1or`frs-t— Amount 15, Sam
g. WATER ZONES (depth):6��(,,
From )S1 To i bo From To
FromV To 551 651 From To
From To From To
6. CASING: Thickness/
From— I • S Depth .0 S Ft. Diameter 2 ( I Vcght ri�
From To Ft.
From To Ft.
7. GROUT: Depth
eCr
Material Method
From 30' To 0 Ft. R.w/r.m. fe fo�r
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From To
From
From
9. SAND/GRAVEL PACK:
Depth
From
From
From
in. In.
in. in.
in. in.
Size Material
To Ft
{o
T Ft.
10. DRILLING LOG
From
o- l5
iS-. Sit
- 55
To Formation Description
yvar-
3G- yS
Ci c/ a✓�
t(D
11. REMARKS:
),u sc rtcJr
Yu-/ ✓�/C
gram/ h-
Information Processing Unit
!DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORBEEN PjtOVIDEDTO THE WELL OWNER.
y l�ti/
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
P l"7.oS51°?`f
P IR N ED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality wiahin 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-lb .
Rev. 7/05