415198_Well Construction - GW1_20130812

NON RESIDENTIAL
North Carolina Department of Environment and
WELL CONSTRUCTION RECORD
Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICA
1. WELL CONTRACTOR:
William T Duggins
Well Contractor (Individual) Name
Terracon
Well Contractor Company Name
5240 Green's Dairy rd
Street Address
raleigh NC 27616
City or Town State Zip Code
(919 ) 873-2211
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) N v4.4
3. WELL USE (Check One Box) Monitoring it/Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 12/11/12
4. WELL LOCATION:
5210 us 421
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Hanover
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ytlat DRidge ❑Other
LATITUDE 34
"DMS oR 19.5231 DD
LONGITUDE 75 " DMS OR 59.0167 DD
Latitude/longitude source: 3PS OTopographic 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.)
New Hanover County Landfill 6 S- o `(
Facility Name Facility ID# (if applicable)
5210 US 421
Street Address
Wilmington NC 28403
City or Town State Zip Code
Andy Mti1vly
Contact Name
5210 US 421
Mailing Address
Wilmington NC 28403
City or Town State Zip Code
( 910.Q 508-2960
Area code Phone number
6. WELL DETAILS:
a, TOTAL DEPTH: 30
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO l/
c. WATER LEVEL Below Top of Casing: 8.52 FT.
(Use "+" if Above Top of Casing)
TION # 3423A
41.5198
d. TOP OF CASING IS 3.13 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 Diameter Weight Material
Top Bottom 20 Ft. 2 inch shd 40 pvc
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 15
Top 15 Bottom 17
Material
Ft. cement
Method
trimmie
Ft. bentonite pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 20 Bottom 30 Ft. 2 in. .10 in. pvc
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 17 Bottom 30 Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / 30
/
BY
Formation Description
tan to brown fine to coarse sand
12. REMARKS:
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SIGNATURE
OF ERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTPFGeTING THE WELL
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN P IDE TO THE WELL OWNER.
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