398422_Well Construction - GW1_20110930

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Corolina Department of Fnvirnnment and Natural Reanurccs• I )ivisinn of Water tQualit)
WELL CONTRACTOR CERTIFICATION q 3002A
.39842
1. WELL. CONTRACTOR:
14/e / , al wcn
Well ontr_actor (Individual) Name
2O u^'1 (f4-7,e_u w6
Well Contractor Company Name ,�/
STREET ADDRESS /'ly /r/i t.si_ A.
47O„go,- fie //2
City or Town State
( 70V ). 76y- (TO rr. ,
Zip Code
Area code- Phone number
2. WELL. INFORMATION:
SITE WELL ID MN applicable)
STATE WELL PERMIT/(N applicable)
DWQ a OTIIER PERMIT a(it applIcable)_•_,_
WELL USE (Check Applicable Box) Monitoring 0
industrial/Commercial p Agricultural C7 Recovery
irrigation° Other. ID (Nit use)
/D = //%
MunicipaUPublic (I
Cl Infection r.T
DATE DRILLED `i// Ir///
° PM a
au rof✓
TIME COMPLETED S•bo AM
3. WELL LOCATION:/
CITY: b-)A0-hriz./ COUNTY
• 0/f2-13C./ w47-0 Lo—#/9A.
(Street Name. Numbers. Community. Subdivision. Lot No.. Parcel. Zip Codel
TOPOGRAPHIC 1 LA,ND SETTING:
0Slope °Valley efrist °Ridge 0 Other
(check appropriate box)
LATITUDE j. s o O/ . 261 n/
May be in degrees.
minutes, seconds or
in a decimal format
LONGITUDE gi r-) a 40- 037 W
Latitude/longitude source: p'GPS °Topographic
(location of wet must be shown on a USGS
attached to this form If not using GPS)
4. FACILITY• n the name of Ili business where the wen is
FACILITY ID e(il applicable)
map
topo mep end
hated.
NAME OF FACILITY
STREET ADDRESS
City or Tam State �� Zip Code
CONTACT PERSON VA-rpf l�v?N
MAILING ADDRESS 5/2 /1-�65/ow-,
' 1 JA>ci NG 2S/ 73
City or Town State
( -70a ). ern -V1372.
Zip Code
YES 0 NO p'
`1 FT.
Area code • Phone number
5. WELL DETAILS:
/
a, TOTAL DEPTH: 30 5-
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Bak* Top of Casing: f
(Use'*' i( Above Top of Casing)
d. TOP OF CASINO IS / FT. Above Lend Surface'
'Top o1 casing terminated a (or below land surface may require
e variance In accordance with 15A NCAC 2C .0116.
e. YIELD (gpm) O METHOD OF TEST Al
1. DISINFECTION: Type "7o //nF Amount 20 oZ-
g. WATER ZONES (depth)
From /03 . To /of%' From „78tr To ..Zi76.
From /p� ' To /O5'' From To
From /17' From To
6. CASING: Thickness/ 5D&21
Depth Diameter Weight Mathes)
From 0 To '3 Ft G % 5.b,e2( /'vG
From To FI
From to Ft
7. GROUT: Depth
From_ 0 _ To Zo -FI
From To_ Ft.
From To� Ft
Material Method ^
ToNtre
rtP
6. SCREEN: Depth Diameter Slot Sire Warfel
From To Ft. in. In.
From To Ft. in. In.
From To Ft. In. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From To FI.
From To Ft.
Froin To Ft.
10. DRILLING LOG
From To
O - G'
7' - /0
// -- .�'S'S�
`13 — 305'
11. REMARKS:
Formation Description
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E r l l ir"m
6 w— a— S YA d ,
r
SEP 3 0 2011
��.ioervrr n'fUCel5S$t j. LSIeet
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1 DO HEREBY CERTWY THAT THIS WELL WAS CONSTRUCTED N ACCORDANCE Wtnt
1SA NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY Of THIS
RECORD HAtEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
(L -D
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1817 Mall Service Center — Raleigh, NC 27899.1517 Phone No. [phone] ext 568.
Form GW1b
Rev. 7105