403984_Well Construction - GW1_20120203

{
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION #:
1. WELL CONTRACTOR:
D. T. Chalmers, Jr.
Well Contractor (Individual) Name
CATLIN Engineers and Scientists
Well Contractor Company Name
220 Old Dairy Road
Street Address
Wilmington
City or Town
( 910) - 452-5861
Area code - Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT #: N/A
OTHER ASSOCIATED PERMIT # (if applicable): N/A
SITE WELL ID # (if applicable) USTPP3343 —MWO1
3. WELL USE (Check One Box): Monitoring ® Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation ❑ Other ❑ (list use).
DATE DRILLED: December 12, 2011
4. WELL LOCATION:
Building PP-3343, MCB Camp Lejeune,
North Carolina
State
28405
Zip Code
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Jacksonville COUNTY: Onslow
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑ Valley ® Flat ❑ Ridge ❑ Other:
LATITUDE:
LONGITUDE:
34.685115 DD
77.368963 DD
Latitude/longitude source: ® GPS ❑ Topo. map
(Location of well must be shown on a USGS topo map and
attached to this form if not using a GPS.)
5. FACILITY (Name of the business where the well is located.)
N/A N/A
Facility Name Facility ID # (if applicable)
Building PP-3343, MCB Camp Lejeune
Street Address
Jacksonville NC
City or Town State Zip Code
Ms. Jenni Provost
Contact Name
Attn: I&E/ EMD/ EQB/ PSC Box 20004
Mailing Address
Camp Lejeune
City or Town
(910)- 451-5068
Area code - Phone number
NC
State
6. WELL DETAILS:
a. TOTAL DEPTH: 17
28542-0004
Zip Code
• I DO HEREBY CERTIFY THAT THIS WELL WA 1�
• 15A NCAC 2C, WELL CONSTRUCTION STAN
• RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO ®
c. WATER LEVEL Below Top of Casing: 10.76 FT.
(Use "+" if Above Top of Casing)
•
•
•
d. TOP OF CASING IS 0.00 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): N/A METHOD OF TEST: N/A
f. DISINFECTION: Type N/A Amount: N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING:
Thickness/
Depth Diameter Weight Material
Top 0 Bottom 7 Ft. 2 in. Sch. 40 PVC
Top Bottom Ft. in.
Top Bottom Ft. in.
8. GROUT: Depth Material Method
Top 0 Bottom 1 Ft.Portland Cement Surface Pour
• Top 1 Bottom 5 Ft. Bent. Pellets Surface Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
• Top 7 Bottom 17 Ft. 2 in. Slot .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
• 10. SAND/GRAVEL PACK:
• Depth Size Material
Top 5 Bottom 17 Ft. #2 Medium Torpedo Sand
• Top Bottom Ft.
Top Bottom Ft.
• 11. DRILLING LOG
• Top Bottom Formation Description
SEE
RECE1
12. REMARKS:
ATTACHED
FEB 032012
WATER QUAUT ' SECTION
THAT A COPY OF THIS
TUOF C 'TIFIED W LL CONTRACTOR
: D. T. Chalmers, Jr.
//7/./i1770
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 27699-1617, Phone No. [phone]
Modified from
Form GW-1 b
Rev. 2/09