398441_Well Construction - GW1_20110930

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina hepanment of Environment nod Nnturnl Resources• I Nvisinn of \Voter OpailO
WELL CONTRACTOR CERTIFICATION N ,q002. A
1. WELL CONTRACTOR:
441141E L, OLIvt R
Well Conntrcc
ata (Individual) Name
AgoU^rA o
Wen Contractor Company Name_
STREET ADDRESS 1.40/1I /I'1eOU.+ A.
2-,,z
City or Town Slate
( 7o y ). 7/r ii ^ gberr
Area code. Phone number
2. WELL INFORMATION:
SITE WELL ID RS applcable)
STATE WELL PERMIT$°( applicable)
DWQ or O7IIER PERMIT N(1? applicable)._._�I-
WELL USE (Check Applicable Box) Monitoring C7 Municipal/Public f I
Industrial/Commercial 0 Agricultural C7 Recovery Cl injection fl
Irrigation& Other © (1st use)
OATS DRILLED to//O///
TIME COMPLETED S=o0
3. WELL LOCATION:
CITY:. ItM1C Eii9t,J
ZIp Code
AM O PM Re
COUNTY avid,"
(Sbaet Nam. Numbers, Community. Subdivision. Lot No.. Parcel. Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
OSIcpe (Valley (Flat DRidge 0 Other
(check appropriate box)
LATITUDE 33'7n/
LONGITUDk .2 R,?3 W
Mar be in degrees.
minutes. second, or
in a decimal format
Latitude/longitude source: OOPS °Topographic map
(bcafbn of ref must be shown on a VSGS topo map and
etched to fhb form r no( uaing GPS)
4. FACIUTY. n ee nem of Os business where the will n located.
FACILITY ID e(If applicaablle)I-1/�
NAME OF FACILITY-11aIa)!1 <117)ISUY)
STREET ADDRESS ,�; rane_ �4 oar
r_eG c98173
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS
City a Town State . Zip Code
514 >• I/03- Salo
NO code • Phone number
5. WELL DETAILS:
a, TOTAL DEPTH: 305'
b, DOES WELL REPLACE EXISTING WELL? YES D NO 2;
C. WATER LEVEL Belo* Top of Casing: 30 FT.
(UM '•' If Above Top of Casing)
39844
d. TOP OF CASINO IS _
'Top o1 casing terminated
• variance In accordance
e. YIELD (gpm) c
FT. Above Land Surface'
el/or below land surface may require
with 15A NCAC 2C .0115.
METHOD OF TEST ma
___
I. DISINFECTION: Type
g. WATER ZONES (depth)
From /00 To /0/
FromJQh ' To /09
From /IV To /y(
7 O`DA All Amount
20 oa.
From To
From To
From To
6. CASINO: Thickneae/
Depth Diameter Weight Material
From f/ To ij7 FI In'/8'' SM.21 vve.
From_.._._.. To.__ Ft
Front To Ft .... _
T. GROUT: Depth Meteriet
From_ 0 T o_ 20 4- Ft Seo•Ta,. I FE
From To Ft.
From To Ft
•
6. SCREEN: Depth
From To
From To
From To
9. SAND/GRAVEL PACK:
Derlh
From
From
From
Ft. In.
FI in.
Ft. _in.
To Fl.
To Ft.
To FI.
10. DRILLING LOG
From To
0 ? 4/
3(/'
o7'
Method
P
Diameter Slot Size Metairie'
In.
In.
In.
Size Materlei
Formation Description
66-IC
47. 30s'r met•_
11. REMARKS:
r- r— tl it ,F re,
as ._.
SEP 3 0 2011
n UUr rrrduun r'rucess►ng U.
rr\--uovv
00 HEREBY CERTI►Y THAT THt3 WELL WAS CONSTRUCTED N ACCORDANCE Wrni
ISA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELI OWNER.
f
$TGNATURE OF CERTIFIED WELL CONTRACTOif DATE
' r+V-IC' L. O1.%'E1l 44- D. mg-14 a -elf
PRINTED NAME OF PERSON C NBTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days, Attn: Information Mgt.,
1517 Mali Service Center — Raleigh, NC 27899.1617 Phone No. [phone] ext 550.
Form GW1b
Rev. 7/05