405538_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 RD
Street Address
PINK HILL
City or Town
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 137
NC 28572
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply [f
DATE DRILLED 7-12-11
TIME COMPLETED 2:45 AM ❑ PM [i
4. WELL LOCATION:
CITY: WALLACE COUNTY DUPLIN
H WY 41 S
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ ValleyFlat DRidge ❑Other
LATITUDE 3 illyf/IYq 6" DMS OR 3X.XXXXXXXXX DD
LONGITUDE 57 2 ° 5 ' 3 2 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
ELEANOR DIXON
Owner Name
HWY41 S
Street Address
WALLACE NC 28466
City or Town State Zip`Code
JUN11Area code Phone number 2012
6. WELL DETAILS:
a. TOTAL DEPTH: 110
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 51
c. WATER LEVEL Below Top of Casing: 15 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): 6 METHOD OF TEST BLOWED
f. DISINFECTION: Type CLORINE Amount 1-3"PILL
nr; 7.731
g. WATER ZONES (depth):
Top 100 Bottom 110 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top +1 Bottom 100 Ft. 2 SC 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 20
Top Bottom
Top Bottom
Ft.
Ft.
Ft.
Method
9. SCREEN: Depth Diameter Slot Size Material
Top 100 Bottom 110 Ft.2 in. 15 in. PVC
•
Top Bottom Ft in. in.
Top Bottom rt. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 90 Bottom 110 Ft. M E D
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
+1 /20
Material
SAND
Formation Description
TOPSOIL SAND
20 / 74 CLAY SAND SHELL MIX
74 /75
75 / 89
89 / 90
90 /99
99 /100
100 /110
/
1
/
1
/
12. REMARKS:
ROCK
CLAY
ROCK
SANDY CLAY
ROCK
WATER SAND �/
REVE1 V
Ju .
Par ri Porto ,
��LMatilena
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.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
71211
DATE
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