396528_Well Construction - GW1_20110802

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
A 38
WELL CONTRACTOR CERTIFICATION # .
1. WELL CONTRACTOR:[
Well Con a or (Individual) Name \ r
II Clitrri_C;vmicacuy Name
RN 12cat
Addrgss
\
City or Town
(nlc_ a F a
State Zip Code
1 ) 5 1 5---- 9 l
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ikricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED S 6 //
4. WELL LOCATION:
cL 7 'USA �r/lg. j Cn>0iu R6j
(Street Name, Numbers, Commu Subdivision, Lot No., Parcel, Zip Code)
•
CITY: 6//U1'0/1)U, AL. e COUNTY a/v i o/i
TOPOGRAPHIC / LAND�SETTING: (check appropriate box)
❑Slope [ValleyL671-lat ❑sct
Ridge ❑Other
LATITUDE awS5 6 ' " DMS OR 3X.XXXXXXXXX DD
LONGITUDE �fr(1�2D j/ " DMS OR 7X.XX3CXX)0(XX DD
Latitude/iongitude source: OGPS ['Topographic map
(location of well must betshown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
t-A +Zig
b2 A Ru Sh,i>1g • rvh_
Mai Address
Ity or own State Zip Code
() as(t-5ga�
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO kt"---
c. WATER LEVEL Below Top of Casing: 30 FT.
(Use "+" if Above Top of Casing)
Top
Top
•Top
et 5v zJ :pis
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): / 2 fM7E/T`HOD OF TEST A J ,/ \
/4'//L
f. DISINFECTION: Type Amount /"/�
%-
g. WATER ZONES (depth):
Top 3/5 Bottom 32 a Top Bottom
Top 37 S Bottom 3 a O Top Bottom
Top Bottom / 36 Top Bottom
• • Thickness/
7. CASING: Depth / . Diameter Weight Material
O Bottom �to b /1 1 /aS
Bottom
Bottom
Ft.
Ft.
Ft.
8. GROUT: Depth Material -/- �1 Method
Top Bottom Ft. sef/v7biv> / e !2 Cq/ip eq'
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
Size Material
11. DRILLING LOG
Top Bottom
V0 1 i70
/ 4';$6
a<�� yav
yt16 / u65j
/
/
/
12. REMARKS:
Formation Description
19m
171
Atl(, (,) ; f 11
Information Processing Unit
nWQ/DOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD BEEN PROVIDED TO THE WELL OWNER.
f
SIGt9I TUR6 CERTIFIED W�ELL� ACTOR DATE
-/ t
(76)) ry !'1, �''�u •
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