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HomeMy WebLinkAbout394420_Well Construction - GW1_20110602S REET ADDRESS ESS NON ON ESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # .Z 0 1, WELL CONTRACTOR: V.:11 Contractor ndivl)J e Well Contractor ComparV me() dCA.. C. C'ty or Town State Zip Code - - (3 Area code- Phone number 2. WELL INFORMATION: SITE WELL ID #(it applicable) STATE W ELL PERMIT#(if applicable) S DWQ or OTHER PERMIT #(if applicable) WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public ❑ Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0 Irrigationher p list use) DATE DRILLED "'C'- 6 "-Z.- TIME COMPLETED AMID PM 3. WELL LL-O-CATt ON: CITY: \�.1r 1 t (� ( COUNTY (AAA..1 u'`SV C.-J co l;rv` Q 596 (Street me Num bers, mbers, Community, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING: ❑Slope OValley at 0Ridge 0 Other (check appropriate box) LATITUDE 3 5 1 (J,�j o9 LONGITUDE O 6 s 3 5 "f' `. May be in degrees, minutes, seconds or in a decimal format Latitude/longitude source: D.G Ss- -Topographic map (location of well must be shown on a USGS topo map and attached to this form d 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 { j State CONTACT PERSON VU \ l -a rw Zip Code tCr;0 MAIUNG DDRESS Af,C City or Town State ( )- 6 e- Z _.- c,L 7 Area code - Phone number 5. WELL DETAILS: a. TOTAL DEPTH: So oA.0/in% _d 8 `r Zip Code b. DOES WELL REPLACE EXISTING WELL/ 55 YES 0 NO c. WATER LEVEL Bela, G. Top of Casing: 3 . FT. (Use "*" if Above Top of Casing) d. TOP OF CASING IS 1 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 R. R- f. DISINFECTION: Type r `5 Amount SC. `^-(�' 7`e c`ry 4 g. WATER ZONES (depth): To From From To �'VI From To From Tod D'w �('� c� From To From To 6. CASING: Thickness/ -t< Depth, r i iarpeter Weight atria From .� To ` t� Ft. ((. "e we- 2 1 C. , From To Ft. From To 'Ft. 7. GROUT: From 0 From Depth , _Materi I + Method A To Ft. �— From To Ft. 8. SCREEN: Depth Diameter Slot Size Material From To Ft. in. in. From To Ft. in. in. From To Ft. in. in. 9. SAND/GRAVEL PACK: Depth From From From Size Material To Ft. To Ft. To Ft. 10. DRILLING LOG om To ( Formation DescriptionA 'cis 11. REMAR S: .. -(� S 1tt4 lc 4--UW t e> \� `4n„- \-c�0..t< 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL O W NEgg SI ATURE CERTIF)D WEL�O CTOR DATE PRINTED NE OF PERSON CiLSTRUCTING THE WELL JUN 0 2 2011 Drr,r..acconn Unit ntn/rsIROC, Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., 1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. (919) 733-7015 ext 568. Form GW-1b Rev. 7/05