405536_Well Construction - GW1_20120611

c. WATER LEVEL Below Top of Casing: 18 FT.
(Use °+" if Above Top of Casing)
d. TOP OF CASING IS +1 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): 20 METHOD OF TEST BLOWED
f. DISINFECTION: Type CLORINE Amount 1-3" PILL
❑ Slope ❑ Valley
LATITUDE *,,
1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2616-A
JIMMY S QUINN
Well Contractor (Individual) Name
QUINNS WELL DRILLING
Well Contractor Company Name
324? POTTERS HILL RD
Street Address
PINK HILL
City or Town
( 252) 568-2380
NC
State
28572
Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 139
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Pr
DATE DRILLED 3-25-11
TIME COMPLETED 2:00 AM ❑ PM El
4. WELL LOCATION:
CITY: BEULAVILLE COUNTY DUPLIN
CABIN ST
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
Flat Q Ridge
20
LONGITUDE *512 °
(check appropriate box)
❑ Other
" DMS OR 3X.XXXXXXXXX DD
" DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source:PS :Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
BERRY MOBLEY
Owner Name
109 S KENNEDY RD
Street Address
BULAVILLE
City or Town
(919 ) 298-2331
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 95
NC 28518
State j zip Code
•
•
•
•
g. WATER ZONES (depth):
Top 80 Bottom 95
Top Bottom
Top Bottom
7. CASING: Depth
Top 85 Bottom 95
Top Bottom
Top Bottom
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
„s,
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft. 2 SC40 PVC
Ft.
Ft.
Material
Ft. BENTONITE
Ft.
Ft.
Method
POORED
9. SCREEN: Depth Diameter Slot Size Material
Top 85 Bottom 35 Ft.2 in. 15 in. PVC
Top Bottom
Top Bottom
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
: Top 80 Bottom 95 Ft. MED
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0
18
35
51
79
80
/18
/35
/51
/79
/80
/95
/
/
/
/
/
JUN 11 2012 : 12. REMARKS:
•
} •
b. DOES WELL REPLACE EXISTING WELL? 'YES-p NO gr
i DO HEREBYCERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
: STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
Ft.
Ft.
Material
SAND
Formation Description
DIRT/CLAY
SAND
CLAY
SAND
ROCK
WATER SAND
RECEIVER
f�
(4 2
informseenP
UttlitaBOG
3-25-11
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
JIMMY S QUINN
PRINTED NAME OF PERSON CONSTRUCTING 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-la
Rev. 2/09