415193_Well Construction - GW1_20130812

NONRESIDENTIAL 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 kit! applicable) NI IA/— 9
3. WELL USE (Check One Box) Monitoring ttif Municipal/Public ❑
Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/13/12
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 ❑ Other
LATITUDE 34
LONGITUDE 77
" DMS OR 19.2105 DD
° ° DMS OR 59.2568 DD
Latitude/longitude source: lial3PS Dropographic 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 it 6S - Pi(
Facility Name Facility ID# (if applicable)
5210 US 421
Street Address
Wilmington NC 28403
City or Town State Zip Code
Andy reiztivvit. Mu Lvey
Contact Name /
5210 US 421
Mailing Address
Wilmington NC 28403
City or Town State Zip Code
( 910.0 508-2960
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 30
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (1/
c. WATER LEVEL Below Top of Casing: 12.55 FT.
(Use "+" if Above Top of Casing)
/115193
d. TOP OF CASING IS 3.68 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
Top Bottom Top
Top Bottom Top
Bottom
Bottom
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
Top 0 Bottom 15 Ft. cement
Top 15 Bottom 17 Ft. bentonite
Top Bottom Ft.
9. SCREEN: Depth
Method
trimmie
pour
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:
Formation Description
tan to brown fine to coarse sand
BY
r_ U
13
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 PROVIgED TO THE WELL OWNER,
SIGNATURE OF CERTIFIED WELL CONTRACTOR %DATE
;A.
PRINTED NAME OF PERSO CONST ING 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