415196_Well Construction - GW1_20130812

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3423A
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 Nit applicable) N V4" 6
3. WELL USE (Check One Box) Monitoring E 'Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 12/14/12
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 Vlat ❑Ridge DOther
LATITUDE 34 " DMS OR 19.2397 DD
LONGITUDE 77 " DMS OR 59.1088 DD
Latitude/longitude source: IW PS i]ropographic 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 Landfi 11 6'�-of
Facility Name Facility ID# (if applicable)
5210 US 421
Street Address
Wilmington NC 28403
City or Town State Zip Code
Andy Moltow Mtklvcy
Contact Name
5210 US 421
Mailing Address
Wilmington
City or Town
( 910.Q 508-2960
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 30
NC 28403
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NON/
c. WATER LEVEL Below Top of Casing: 8.45 FT.
(Use "+" if Above Top of Casing)
Formation Description
tan to brown fine to coarse sand
ii tPnRuh- Q,,,�
.A15196
d. TOP OF CASING IS 3.02 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 Material Method
Top 0 Bottom 15 Ft. cement trimmie
Top 15 Bottom 17 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
/
/
12. REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WA
15A NCAC 2C, WELL CONSTRUCTION STAND
RECORD HAS BEEN PRQy1DED TO THE WELL
CEWWE
STRUCTED IN ACCORDANCE W
AND THAT A COPY OF THIS
-7-
SIGNfCTUERTIFIED WELL CONTRACTOR DAT
c, ., ' A.k " < i[ / A 3
PRINTEDNAME OF PERSON CONS�s TRCTING 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