400331_Well Construction - GW1_20111213

L�SiDF'fTI i� WELL CD14STRI]CTIONTtEC0RD
Noun Cirolin5 Depgnmznt of Environment and Natural Resources- Division of %Marar Quality
WELL CONTR CTQR CERTIBICATIC•N.# 2 Z / V —.
1.WELL. CONTRACTOR:
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vv al Conus:t i tnoiv mi ama
A o Gcf S �yyY//4 4 eclz //
tWett Conu3:tor company Nona
STREET ADDRESS p Q /.36 x
4U/.ct
Cite .fit Town
Burt
istw :aaa- Pnona nvmasr
YrtLL 1nFJRkt:.TION:
atTE vvELL 1D intapplicsatzl
.Ur•/1.
Z. L/ Z—
ZS'e 7
Zip Coln
ti4
S TAT WELL PERMITirtr appticacwl i{/ 14
O WQ x OTHER PERMIT t(il ippliciGlc) /� /S 4
WELL USE ICiwt,: Appocinio Bat): Rasirtential Waiar Supply C-a"
D. JE ORILLEt7 /
TUE COt4PLETED `/...3 U
3. WELL LQ.CyATIIQN; A7e COUNTY U�/' 6
i=urAt N.ma t+wnoas, Cwnmunuy. Suoarvtslan, LQt HC Pzreal, Zip Cade)
TtOP0GRAPYiIC I LAND SETTING:
LlSt pe QV;u4Y i QRjg9s OOhc(
icnact; :pprppnaic box)
LSTiTuDE 3 �
LONGITuGE Sk Q aGS`3
AMO PMC—
May be in degrees,
minutes, seeonua or
in a decimal format
Litio.i 4/Iongituda source: 10.2rffS OTopograpJtit: map
I ,3c3=.Ian of wau must oa shown on a VSGS iopo map anti
aaacnaa to finis. form if not using GPS)
�. WELL OWNER
OWNER'S NAME
STREET AOQRES$ 23/7
,�vs �k Z/G?
Zip Calo
Gty or Torre Stare
ZZ CLY,_
:Vara cCaa • Pnona nuITIOW
WELtiDETAILS:
a. TOTAL DEPTH:
GC
r;fli
D. DOES WELL REPLACE EXISTING WELL'? YES C1 NQ (]
c. WATER LEYFL Sawa -Top of
(434'_' it Above Top to C:sin9j
Q. TOP OF Ci.SING 15 / L
FT. Above L-arlq Suriacr
'Top of wui9 tarnun,tea oilor tulaw land surface may require
ririvlc2 N LCcordlnca YrjU% 13Pt NCAC 2C .0118.
e.Y1E1_0 Wpm):/ METF100 OF TE$T I7`
33
400.
r, DISINFECTION:Typap /9Ore J//r Amvunr'S G -te,"
9. WATER ZONES (depth):
• ..From 3 a C To 3 2--/ From Tq
From_ To From To
From To From To
4. CASING: Thickness/
0a Dumpier WoigflI Materal
Fr 1_
Frart> Tp 6 a Ft. Gt .$i7.924 jf'C.
From To Ft. _
7. GROUT: DepN Material Wino/4
Frorn 0 To s O FL/,?e ..L;-i e. to m
From To F.
From Tv FL_
II, SCREEN: Depth Diamotor Slot Sao -
From To Fl, in. In,
From To F. jn. In.
From To Ft. ; in. in.
SANDJGRAVEL PACK:
Depot
from To Ft.
FL
Ft.
From To
From Tv
Size
Malarial
Material
19, ORILLJNG LOG
From To FQ malion Description
C '- `l . YooSG ,
yn: s_ ct/h,-,r:. y. ,,5 o c( y
_Sep;
11. RTiAAARI;.S:
DEC 1. 3 2011
DWOIROQ
I DO t1EREaY CERTIFY THAT -THIS WELL WAS cQ115TRVCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANOARps, A►rpT}V,TA COPY (Willa: —
RECORD HAS aEEN PROviDEATO THE WELL OWNER.
JAeL"
LURE OF C RTIFIED WELL CONTRACTOR
/2-$ /I
DATE
Fc44 1 4u ge 7d ¢ /1
PRINTED NAME CF PERSON CONSTRUCTINGTHE WCLL
Sutmit 1114 originiri 17 tha Division of Water Quality within 30 days. Attn: information M91,,
1017 Jr13il Sarrici C ntvr — Riki9h, NC 27599-1517 Phone Q. [phone] 4-x1954,
Form GW.1a
Roy. 7/95