406554_Well Construction - GW1_20120711

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1. WELL CONTRACTOR:
William Kicker
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4108-B
Well Contractor (Individual) Name
Mad Dawq, Inc.
Well Contractor Company Name
1006 CamD Creek Rd
Street Address
Iron Station NC 28080
City or Town State Zip Code
(704 .) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) AS-14
3. WELL USE (Check One Box) Monitoring (1 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 6-15-12
4nr:4
d. TOP OF CASING IS 0 FT. Above Land Surface*
*Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NIA METHOD OF TEST
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Thickness/
Diameter Weight Material
Top 0 Bottom 20' Ft. 2" Sch40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT:
: Top 0
Depth Material
Bottom 15' Ft. Portland
Method
Trimmie
Top 15' Bottom 18' Ft. Bentonite Pour
Top Bottom Ft.
4. WELL LOCATION:'
9. SCREEN: Depth
5200 Wrightsville Ave : Top 20' Bottom 25'
Top Bottom
CITY: Wilminaton COUNTY New Hanove ; Top Bottom
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Valley iifFlat [p Ridge ❑ Other
LATITUDE 34 12 7os.0000 " DMS OR 3x.xxxxxXxXX DD
LONGITUDE 77 0 51 , 980.0000 " DMS OR 7X.xxxxxxxxx DD
Latitude/longitude source: WIPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Former Scotchman #1$2
Facility Name
5200 Wrightsville Ave
Street Address
WilCnington
City or Town
Bryan Lievre
Contact Name
P.O. Box 12055
Facility ID# (if applicable)
NC 28403
State Zip Code
Mailing Address
Wilmioaton N_C 28405
City or Town State Zip Code
( 910 n 932-3050
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 25'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO riff
c. WATER LEVEL Below Top of Casing: 8' FT.
(Use "+" if Above Top of Casing)
: 10. SAND/GRAVEL PACK:
• Depth
Top 18' Bottom
Diameter Slot Size Material
Ft. 2" in. .010 in. PVC
Ft. in. in.
Ft. in. in.
Size Material
25' Ft. #2 Silica
: Top Bottom Ft.
: Top Bottom Ft.
. 11. DRILLING LOG
Top Bottom
Formation Description
0 / 25' Silty Sand
/
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION S ANDAR, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TOlTELL
6-/ 1- id
....
SIGNATURE OF CERT DIED WELL CONTRACTOR DATE
: i'a///et-Vi'L
PRINTED NAME OF PERSON CONSTI
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
fi .G ✓
TIN THE WELL
Form GW-lb
Rev. 2/09