406557_Well Construction - GW1_20120711

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4108-B
1. WELL CONTRACTOR:
William Kicker.
Well Contractor (Individual) Name
Mad Dawq, Inc.
Well Contractor Company Name
1006 Camp Creek Rd
Street Address
d. TOP OF CASING IS 0 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
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Iron Station NC 28080 : Top N/A Bottom Top Bottom
City or Town
State Zip Code
: Top Bottom Top Bottom
(704 ) 732-0213 : Top Bottom Top Bottom
Area code Phone number
2. WELL INFORMATION: : 7. CASING: Depth
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) AS-17
3. WELL USE (Check One Box) Monitoring d Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 Wrightsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Hanova
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley Flat ❑Ridge ❑Other
LATITUDE 34 ° 12 , 716.0000 DMS OR 3X.XXXXxxxxx DD
LONGITUDE 77 ° 51 ' 974.0000 ° DMS OR 7X.XXXXXXxXX DD
Latitude/longitude source: WXPS ❑Topographic map
(location of well must be shown on a USGS topo map andaftached to
this form if not using GPS)
Top
0
Bottom 20'
Thickness/
Diameter Weight Material
Ft. 2" Sch40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT:
Top 0
' Top 15'
Depth
Bottom 15'
Material
Ft. Portland
Bottom 18' Ft. Bentonite
Top Bottom Ft.
Method
Trimmie
Pour
9. SCREEN: Depth Diameter Slot Size Material
Top 20' Bottom 25' Ft. 2" in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
•
: 90. SAND/GRAVEL PACK:
Depth Size Material
▪ Top 18' Bottom 25' Ft. #2 Silica
Top Bottom , Ft.
: Top Bottom . Ft.
: 11. DRILLING LOG
5. FACILITY (Name of the business where the well is located.) Top Bottom
Former Scotchman #182
Facility Name
5200 Wrjahtsville Ave
Facility ID# (if applicable)
Street Address
Wilminaton NC 28403
City or Town State Zip. Code •
Bryan Lievre
•
Contact Name
P_O. Box 12055
Mailing Address
Wilmington NC 28405•
City or Town State Zip Code
( 910,E 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO I/
c. WATER LEVEL Below Top of Casing: 8' FT.
•
•
•
(Use "+" if Above Top of Casing)
.
0 /25'
/
/
/
/
/
12. REMARKS:
Formation Description
Silty. Sand
1,741.. r
< l;
•
.1f 1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION ANDARDS, AND THAT A COPY OF THIS
: RECORD HAS BEENPROVID D TWELL OWNER.
PE
SIGNATURE OF CER I ED WELL�CC�iNTRACTOR
PE
40"-fq*Ia2
DATE
PRINTED NAME ��I� CON$TRUCTYNG 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 b
Rev. 2/09