GW-1Jul 06 15 09:21 a Cape Fear Well & Pump Co.
WELL CONSTRUCTION RECORD
This form can be used for single or multiple [veils
I. Well Contractor information:
{ A
s_1!leY]C�C (7� L Ll
'A'01 Contnctor Name
aW.) -A
NC Well Contractor Cenification Number II
"1' 1
Comp Name
2. Well Construction Permit #:
List all applicable well catstructioa perntfls (i.e. Comrty, Stale, Yariance,
3. Well Use (check well use):
Water Supplg Well:
OAgricultura! ❑��M�unicipal/public
OGeoibcnnal (Heating/Cooling Supply) ❑'Kesidential Water
❑IndustrialICommcrcial ❑Residential crater
❑Irrigation
Aon -Water Supply Weil:
6. Ir(are) thewell(s): or OTemporary•
V-
7. Is this a repair to an existing well: ❑%'es or o
if this is a repnin fill oui brown x et! eorub'rrdlwr irrjownatiar and eipiain to
repair [older #21 remarksrection or ors Nie bacA of flits form.
S. Number of wells construeted:
For multiple fgjectfar or rton-x ater sre,ppt stir/is O. LY u•i+fi f(re same coasts.
subatit auejiirm.
+
9. Total well depth beloti land surface:
For nutlHpleweltrice+ all depolsy^&#ererrt(example-200•oad2Q(G0')
III. Static water level below top of casing: ry�
xt+
llfater le el fs above casing, use "r"
11. Borehole. diameter: (in.► _
12. Well construction method: _
(i.e, auger, rotary, cable, direct push, etc.)
I3. FOR IVATER SUPPLY WELLS ONLY:
13a- Yield (gpm) C2 C) rvlethod of test:
13b.Disinlectiontype: 141 Amount:
(single)
(shared)
No. (PIN)
al degrees:
W
nagrre oj'Nre
ctur
910-486-7054 p.1
For Internal Use ONLY:
,au
FROM TO DESCRIP'T'ION
r ft• t ft.
DAtluifer Recharge
OGroundwaterRem
❑Aquifer Storage and Recovery `
❑Satinity Barrier
❑Aquifer Test
❑Stormu'ater Draina
OExperimentat Technology
❑Subsidence Contro
❑Geothermal (Closed Loop)
❑Tracer
❑Geotherrnal (Heating/Cooling Return)
❑Other (explain undi
4. Date Well(s) Completed:
5- Well Location.
Facility/Owner Name
Facility 1D9 (ifapt
ct p
Physical Address -Ci , and Zip
•�—
County
parcel Ideutificatio
5b. Latitude and Longitude in degreeslminutes/seconds or decir
(if well fueld, one latllongissufficient)
N
6. Ir(are) thewell(s): or OTemporary•
V-
7. Is this a repair to an existing well: ❑%'es or o
if this is a repnin fill oui brown x et! eorub'rrdlwr irrjownatiar and eipiain to
repair [older #21 remarksrection or ors Nie bacA of flits form.
S. Number of wells construeted:
For multiple fgjectfar or rton-x ater sre,ppt stir/is O. LY u•i+fi f(re same coasts.
subatit auejiirm.
+
9. Total well depth beloti land surface:
For nutlHpleweltrice+ all depolsy^&#ererrt(example-200•oad2Q(G0')
III. Static water level below top of casing: ry�
xt+
llfater le el fs above casing, use "r"
11. Borehole. diameter: (in.► _
12. Well construction method: _
(i.e, auger, rotary, cable, direct push, etc.)
I3. FOR IVATER SUPPLY WELLS ONLY:
13a- Yield (gpm) C2 C) rvlethod of test:
13b.Disinlectiontype: 141 Amount:
(single)
(shared)
No. (PIN)
al degrees:
W
nagrre oj'Nre
ctur
910-486-7054 p.1
For Internal Use ONLY:
,au
FROM TO DESCRIP'T'ION
r ft• t ft.
ft. ft.
15. OUTER CASINGfor multi•co cd Its OR LINER if applicable)
FROM - TO 1.—i'TER TIIICIICiESS I MAMERUL
' ft 1 t ft. 7I J& in.
SbR
M INNER CA51,VGORTU13ING eatirerma[closed
loo
FROM TO DULIETEA THICrCYESS 6L4TERL�L
22. Certification:
�/�r�/� D T
Kl ✓rl�f// I
Si use of CeKified Well Contractor Dale
By signing 114sf-774 I hereby ceriff i• that the well(r) war (xrre) caistrncYed in accordance
copy ofNTis record har beta provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well silt: details or lie)1
construction details. You may also attach additional pages ifnecessary.
24. Submittal Instructions:
.(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to die fallolsing.
(lt•) Division of Water Quality, Information Processing Unit,
1617 hail Service Center, Raleigh, NC 27699-1617
24b. For Initetion Wells: In addition to sending the fore to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
I1636111ail Service Center, Raleigh, NC 27699.1636
24c. For Nater Supply R Geothetrntal lYelis: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the count, health department of the count
where construcred.