406547_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-7
3. WELL USE (Check One Box) Monitoring (i 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 Wriahtsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton couNTYNew Hanove
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley itFlat ❑ Ridge ❑Other
LATITUDE 34 0 12 ' 709.0000 " DMS OR 3X.XxxxxxxXX DD
LONGITUDE 77 0 51 966.0000 ISMS OR 7X.XXXxxXXxX DD
Latitude/longitude source: 3PS ❑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.)
Former Smtch man #182
Facility Name Facility ID# (if applicable)
5200 VVriahtsville Ave
Street Address
Wilminaton NC 28403
City or Town State Zip Code
Bryan Lievre•
Contact Name
P _ O _ Box 12055
Mailing Address
Wilminaton NC 28405
City or Town State Zip Code
� 91 Q,fi 932-3Q50
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 50'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 8'
(Use "+" if Above Top of Casing)
YES ❑ No El
FT.
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): ill/A METHOD OF TEST
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top NIA Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 45' Ft. 2" Sch40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 40' Ft. Portland Trimmie
Top, 40' Bottom 43' Ft. Bentonite Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top 45' Bottom 50' Ft. 2" in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 43' Bottom 50' Ft. #2 Silica
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
• 0 / 50'
•
/
/
12. REMARKS:
Formation Description
Silty Sand
Z
PNSTR: 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 0 T E WELL O NER.
/ Za—(4L1
SIGNATURE RTIF D ELL NTRACTOR DATE
P
/Z1?-br-
PRINTED NA UTING THE WELL
ERSbN CO ERS NCO
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