406268_Well Construction - GW1_20120723

N tik CbrOliil M.t
WELL CONST. .
p .
Etwiitifinieitit and Natural „
d •
EAP71
WELL CONTRACTOR CERTIFICATION # 3351
1 WELL CONTRACTOR:
Michael Wilson
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9088 northf ield dr.
ft .mill sc
29707
:city.- or Too State Zip Code
( y. [phone]
Area code PhOr10. number
. 2. WELL INFORMATIOW
-Sterg:WELLip It(it applicOlp). mw
STATE WELL PERMIT#(1f..,wilitabie)
DWQori:OTHER PgRmIT:#(i.f.:appliCable)
WELL USEICMCKAPpliCab16.18.0k).MonitOrindz
induStrial/COmmercial 0 -Agricultural 0 :Recovery.D InjectiOn-
IrrigationEl Other.E3 (Ust use
DATE pRiLLEn. 6-20-12
iim..EPQMPLIETED, 12 ; 3 o
WELL LOCATION:
.wilmington
2
AM 0 P
UNTY new hanover
3612 us-421
(StreetIName,i Numbers, Community,SubdiyiSion":1;17No,:iarteFilp7aode)
TOPOGRAPHIC,/ LAND SETTING
D Slope EA/alley igl Flat ELIRidge El Other.
(t:heek.gipprqpr)plebp4
LATITUDE 33,29467
LONGITUDE 77,97245
May be in degree5.
Latitude/longitude source: GRS EfroPogilifi:hicm40
(Iocation Of vitteltrnyst.:08 $howp on a USGS topo• Map and
attachedto not using GPS)
4 FACILITY, i.ttle*nprile.'of the busirass where the wet isIpast0.
FACILITY ID #(if applicable)
NAME OF FACILITY wi1±ngon maerialp
STREET ADDRESS 3612 us-421
wilmington
nc
City or Town State
CONTACT PERSON j a son ki 1 coyne
MAILING ADDRESS 911 keisler dr,
cry nc
City or Town State
( 919 .)- 858-9898
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 15
b. DOES WELL REPLACE EXISTING WELL? YES E NO
c. WATER LEVEL Below Top of Casing: ET.
(Use "+" if Above Top of Casing)
28401
Zip COP
27518
Zp Code
1
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.
METHOD OF TEST
ec YIELD (gpm):
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From To
From To
From _To
6, CASING: Thickness/
Diameter Weight Material
Ft, 2"
Depth
From 5 To 0
Fr To
•From
From To
From To
From To Ft,
SHC 40 PVC
.7. GROUT: Depth: Material • Method
FtOm31..................., TO°......................„-Ftl..P°rtlandtrimmie..................,
From .. TO:. ..." FL
. From _ . _, TO ,..Ft....
8:. SCREEN: " . Deptil. Diameter. ;Slot •:Sim
RitititTo ,„,,„• Ft.: b. . .. itt, PVIVicatettial
From TO Ft. In. in...,. •
From 15 To 5 . Ft:2 " in ,, i o Im:.
SAND/GRAVEL PACK:
Depth Size Material
From15' To 41 Ft ..#2
'ROM To
From • To Ft.
. • .
sand
DRILLING LOG
Frorn To
0 15
11. REMARKS:
Forrn406hDescription
TAN, AND... S
• ••
JUL 2 3 ZU
•
JUN 2m 2012
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NoAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE
6-20-12
IED VVELL CONTRACTOR DATE
micheal wilson
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Subnlitithe original to the Division of Water Quality within:30.dayS. Mb): Information Mgt.,
1617 Mail Service Center» Raleigh NC 27699,161.7 Phone No. (919).7444410. 0)40.04..
Form GW-lb
Rev. 7/05