390909_Well Construction - GW1_20110120

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
ST izc�i'-_ /b(GA) t Y - -/( Z_
Well Contractor (Individual) Name
S'qi• / CCO
Well Contractor Company Name
,c) - - No'— 1,4 C, I e0
Street Address
rc;n i/C` .SC Zc,7C,7
City or Town State Zip Code
(fob) t y i .O3 5 3
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 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED I- O ( /
4. WELL LOCATION:
600 j OS" t ;AC 02
(Street Name, Numb rs, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: no Iv COUNTY UP /0.J
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope ❑Valley lat q❑Ridge ❑Other
LATITUDE ' 3 c/ cI Z `f ')MS OR DD
LONGITUDE. 8-0 °S S��6 " DMS OR DD
Latitude/longitude source: Qfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
CA/10 l'vm is D r c4 L
Facility Name
(:,OC) /10.5p ,',,C)C D2
Street Address
i'v\o& no '
City or Town
ra r ,a CUC ON./
Cr TlN',.(e4i/e
Facility ID# (if applicable)
mac— 2fsli�.
State Zip Code
Contact Name
k 70 I i2/) U c u ✓>
Mailing Address
C I-)l(ift ►l NL a- .i7
City or Town State Zip Code .
( .70t1) - 37S3
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 3 /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO I
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
�-j
3 99
d. TOP OF CASING IS 0 '0 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
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth r Diameter Weight
TopO. 6 Bottom a0 Ft. I SCP/ YC1
Top Bottom
Top Bottom
Ft.
Ft.
8. GROUV : Depth ( Material
Topes Bottom l A Ft. .41 i C/}"•,0
Top Bottom Ft.
Top Bottom Ft.
9. SCREEIN: Depth i Diameter
Top 9-.0 Bottom 3C.) Ft. A.' in.
Top Bottom Ft. in.
Top Bottom Ft. in.
Material
(-6..
Method
TA( wt/
Slot Size
.oto in.
in.
in.
Material
f vL
10. SAND/GRAVEL PACK:
I Depth I Size/Material
Top 1 c. Bottom 30 Ft. ,OG/3C ,S lc (C4 Si -- I)
Top Bottom Ft. /
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation. Description
U / i )— c i 'y C C✓I ��
�l 3O i3 r7 ✓tG C i C-
/
/
/
/
ECEIIVED
JAN 2 0 2011
/ WATER QUAL1Tv SECTION
Inrorm%dion Processing Unit
12. REMARKS:
, r2_ Cif yiS /6
I DO HEREBY CERTIFY THAT THIS LL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCT N STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BgEN °VIDEO THE WELL OWNER.
i�---
SIGNATURE OF CERTIFIED WALL CONTRACTOR DATE
S 72u 1.T- .� t ,'i (C Z --
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-lb
Rev. 2/09
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