409004_Well Construction - GW1_20121113

I%/ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9088 Northfield
Fort Mill S.C.
29707
City or Town State Zip Code
( 803 )--548-2180__....
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #;if applicable) DMW-1
STATE WELL PERMIT#(if applicable)
IDWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring'A] Municipal/Public D
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation) Other 0 (list use)
DATE DRILLED 10 - 9 -12
TIME COMPLETED 12 :30 AM 0 PM g
3. WELL LOCATION:
CITY: Wilmington
1608 Market Street 28401
COUNTY New Hanover
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope L Valley K1 Flat o Ridge L Other
(check appropriate box)
LATITUDE 34.23731
LONGITUDE 77.92865
May be in degrees.
minutes. seconds or
in a decimal format
La.titudellongitude source: xi GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY- is the name of the business where the well is Iocated.
FACILITY ID #(if applicable)
NAME OF FACILITY Modern Laundry
STREET ADDRESS 1608 Market Street
Wilmington N.C. 28401
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS Same
City or Town State Zip Code
)-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 32 '
b. DOES WELL REPLACE EXISTING WELL? YES L NO
c. WATER, LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
.4: 4 0
rtni
d. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118,
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 27' Ft, 2" SCH 40 PVC
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0' Ton, Ft Portland
From To Ft,
From To Ft.
Method
Trimmie
8. SCREEN: Depth Diameter Slot Size Material
From 27 ' To 32 ' Ft. 2 " in, . 010 in. PVC
From To Ft. in. in.
From To Ft. in. in.
9.. SAND/GRAVEL PACK:
Depth Size Material
From 25' To 32' R. #2 Sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0' 20'
20' 25'
25' 32'
25'
Formation Description
Sand
Clay
Rock
EC
t m/ rl
11. REMARKS:
ln for s. i t
p;WW:BC6
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I DO HEREBY CERTIFY THAT THIS l�.r - f 4AS CONSTRUCTED IN ACCORD WITH
15A NCAC 2C, WELL CONSTRUCTION ° NDARDS, AND THAT A COPY OF
RECORD HAS BEEN PROVIDED TO THE 'Jt"� L
10-12-12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Randy Hoffman
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-lb
Rev. 7/05