405537_Well Construction - GW1_20120611

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
3242 POTTERS HILL NRD
Street Address
PINK HILL
City or Town
( 252) 568-2380
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 149
NC 2857?
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply I
DATE DRILLED 7-19 11
TIME COMPLETED 4:30 AM p PM fft.
4. WELL LOCATION:
CITY: TEACHEY
COUNTY DUPL1N
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAN I - ETTING: (check appropriate box)
o Slope [Valley r1 lat 0 Ridge D Other
LATITUDE S37?(iJ 3 ? "DMS OR 3X.XXXXXXXXX DD
LONGITUDE iv,' ' -7 J& 3 " DMS OR 7X.)00000X000X DD
Latitude/longitude source: CaGS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
CYNTHIA HARRELL
Owner Name
PROVIDENCE.QHURCH 331
Street Address
TEACHEY
City or Town
(910 ) 282-2888
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 195
►N ; ,28464
State':.: I Zip 'Code'
JUN I 1 2012
b. DOES WELL REPLACE EXISTING WELL? _...YES1 .•_"_NO"C ..
c. WATER LEVEL Below Top of Casing:. 26
(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.
FT.
e. YIELD (gpm): 25 METHOD OF TEST BLOWED
f. DISINFECTION: Type CLORINE Amount 2-3"PILI.L
•
•
•
•
•
•
•
g. WATER ZONES (depth):
Top 170 Bottom 195
Top Bottom
Top Bottom
7. CASING: Depth
Top + 1 Bottom 170
Top Bottom Ft.
Top Bottom Ft.
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft 2 SC40 PVC
8. GROUT: Depth Material
Top 0 . Bottom 20 Ft. BENTONITE
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Method
POORED
Diameter Slot Size Material
Top 170 Bottom 195 Ft.2
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Top,160 Bottom 195
in. PVC
in.
in.
Size Material
Ft. MED • SANDO
• Top Bottom Ft.,
▪ Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /23
23 /68
68 / 138
138 /139
139 /168
168 /169
169 /195
/
/
/
12. REMARKS:
Formation Description
CLAY SAND MIX
SAND
CLAY
ROCK
SHELL SAND CLAY MIX
ROCK
WATER SAND
REE1VED
Ta. �
Inforrnatkwi Processing Unit
DWQB
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
PROVIDED TO THE WELL OWNER.
7-19-11
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-1 a
Rev. 2/09