408504_Well Construction - GW1_20121022

N ON RESIDENTIAL WELL CONSTRUCTION RECORD
orth Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3470-A
1. WELL CONTRACTOR:
William M Wiaains
Well Contractor (Individual) Name
Mid -Atlantic Drilling Inc.
Well Contractor Company Name
PO Box 315
Street Address
Carolina Beach
City or Town
(910 ) 458-5020
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
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UUI .
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.
CENTRAL Fills: e. YIELD (gpm):
DWQIOG : f. DISINFECTION: Type
NC 28428
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-1
3. WELL USE (Check One Box) Monitoring Il Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 9/5/2012
METHOD OF TEST
Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Weight Material
Top 0 Bottom
Diameter
Ft. 2" Sch 4C PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.5-1 Bottom Ft. bentonite
Top 0-0.5 Bottom Ft. concrete pour
Top Bottom Ft.
Method
pour
4. WELL LOCATION: 9. SCREEN: Depth Diameter Slot Size Material
1624 Castle Havne Road : Top 2 Bottom 12 Ft. 2 in. 0.01
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) Top Bottom Ft. in. in.
CITY: Wilminaton COUNTY N.H.0 : Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley Q "Flat ❑Ridge ❑Other
LATITUDE 34 ° 16 . 1.4100 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 55 47.4100 " DMS OR 7X.X000000xx DD
Latitude/longitude source: ❑GPS ❑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.)
Castle Havne Road -1624 N/A
Facility Name Facility ID# (if applicable)
1624 Castle Havne Road
Street Address
Wilmington NC 28401
City or Town State Zip Code
Randy Burae
Contact Name
1117 Military Cutoff Road
Mailing Address
Wilminaton NC 28405
City or Town State Zip Code
c 910,o 509-3918
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO q/
c. WATER LEVEL Below Top of Casing: 515 FT.
(Use "+" if Above Top of Casing)
•
: 10. SAND/GRAVEL PACK:
Depth
in. pvC
Size Material
Top 1 Bottom 12 Ft. #2 torpedo sand
Top Bottom Ft. natural pack
Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
0
2
6
8
/2
/6
/8
/12
12. REMARKS:
Light brown fine sand
Dark brown fine sand
Dark gray fine sand
Tan fine sand
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OCTy,e F•
BV:.
: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
. REC D HAS BEE)) P OVIDED TO THE ELL OWNE
vJ,/, P}'-. /f /5I12
SIGNATUREOF CERTIFIED WELL'CONTRACTO DATE
: William M. Wiggins
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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