394420_Well Construction - GW1_20110602

S 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. [phone] ext 568.
Form GW-1b
Rev. 7/05