302 Foster Rd (2) ���o
NONRESIDENTIAL ONRESIDENTIAL WELL CONSTRUCTION RECORD RECEIVED
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3214 OCT 0 2 2015
1.WELL CONTRACTOR: d. TOP OF CASING IS 1 1/2 FT.Af'tfe`Ls
RANDY OWNBEY 'Top of casing terminated attor below Ian�a''surfa T
Well Contractor(Individual)Name a variance in accordance With 15A NCAC 2C.01 18.
AIR DRILLING, INC :e. YIELD(gpm): 10 METHOD OF TEST AIR
Well Contractor Company Name ;f. DISINFECTION:Type HTH Amount
176 COMMERCE BLVD
Street Address ;g. WATER ZONES(depth):
STATESVILLE NC 25625 :Top 389' Bottom 390, Top Bottom
City or Town State Zip Code :Top Bottom Top Bottom
7c 04 872-7614 :Top Bottom Top Bottom
Area code Phone number Thickness/
2.WELL INFORMATION: :7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# :Top 0 Bottom 60 Ft. 6" PVC
OTHER ASSOCIATED PERMIT#(if applicable) :Top Bottom Ft.
SITE WELL ID#(if applicable) :Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring❑ Municipal/Public❑ :8. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural j(Recovery❑ injection❑ :Top 0 Bottom 20 Ft. GROUT POURED
Irrigation❑ Other❑ (list use) :Top Bottom Ft.
DATE DRILLED 9-30-15 ;Top Bottom Ft.
4.WELL LOCATION: 9. SCREEN: Depth Diameter Slot Size Material
302 FOSTER RD. :Top Bottom Ft. in. in.
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom Ft. in. in.
CITY: MOCKSVILLE COUNTY DAVIE :Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other :10.SAND/GRAVEL PACK:
Depth Size Material
LATITUDE 35 *51 .153.0000 "DMS OR DD
:Top Bottom Ft.
LONGITUDE 80 " 39 ' 616.0000 "DMS OR DD
— ;Top Bottom Ft.
Latitude/longitude source: ❑GPS Dropographic map :Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) : 11.DRILLING LOG
5.FACILITY(Name of the business where the well is located.) : Top Bottom Formation Description
0' / 50' DIRT
Facility Name Facility ID#(if applicable) 00'/ 405' ROCK
Street Address /
City or Town State Zip Code /
DON BROWN /
Contact Name /
302 FOSTER RD_ /
Mailing Address /
MOCKSVILLE NG 27028 /
City or Town State Zip Code :12.REMARKS:
U
Area code Phone number
6.WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15ANC 2 LL CO STRUCTI STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 405 FT :RECORD EEN P VIDED HE LL OWNER
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO qI :SIG TUR F C TIFIED CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: 40 FT. 6-14(j V(,U O g C 4
(Use"+"if Above Top of Casing) :PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Form /09
y p ty- Information Processing, Rev.2/09
1617 Mail Service Center, Raleigh,NC 27699-161, Phone: (919)807-6300