406551_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 Dawa, Inc.
Well Contractor Company Name
1006 Camp Creek Rd
Street Address
Iron Station
City or Town
( 704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) AS-1 1
3. WELL USE (Check One Box) Monitoring (1 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 Wrightsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Hanove
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope [Valley elat 0 Ridge D Other
LATITUDE 34 0 12 , 688.0000 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 O 51 , 974.0000 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: V3PS QTopographic map
(location of well must be shown on a USGS topo map andfaffached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Former Scotch ma n ## 182
Facility Name
5200 Wrightsville Ave
Street Address
Wilminatop
City or Town
Brvan Lievre
Contact Name
P.O. Box 12055
Facility ID# (if applicable)
.
Top 43'
Top
: Top
: 11. DRILLING LOG
Top Bottom
0 / 50'
:d
•
e
:g
. 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.
. YIELD (gpm): NIA METHOD OF TEST"
#. DISINFECTION: Type N/A Amount
. WATER ZONES (depth):
Top N/A
: Top
: Top
Bottom Top Bottom
Bottom Top Bottom
Bottom Top Bottom
7. CASING: Depth
Top 0 Bottom 45'
: Top
Top
Thickness/
Diameter Weight Material
Ft. 2" Sch40 PVC
Bottom Ft.
Bottom . Ft.
8. GROUT: Depth
Top 0 Bottom 40'
: Top 40' Bottom 43'
Top
Material
Ft. Portland
Method
Trimmie
Ft. Bentonite Pour
Bottom . Ft.
9. SCREEN: Depth
Top 45'
Top
• Top
Diameter Slot Size Material
Bottom 50' Ft. 2" in. .010 in. PVC
Bottom Ft, in. in.
Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Bottom 50' Ft. #2 Silica
Bottom Ft.
Bottom Ft.
/
NC 28403
State Zip Code
Mailing Address
Wilminatop NC 28405
City or Town State Zip Code
( 910,E 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 50'
b. DOES WELL REPLACE EXISTING WELL?
YES ❑ NO
c. WATER LEVEL Below Top of Casing: 8' FT.
(Use "+" if Above Top of Casing)
/
/
12. REMARKS:
Size Material
Formation Description
Silty Sand
; I
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION S NDARDS, AND THAT A COPY OF THIS
: RECORD HAS BEEN E'ROVIDEB T',' H _/ ELL NER.
SIGNATURE OF CERTI
.4.67
PRINTED A�PER O O TRUCTI G THE WELL
'<it/e° —fq-12
D WELL CONTRACTOR DATE
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mali Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09