404630_Well Construction - GW1_20120423

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1. WELL CONTRACTOR:
Ronald E Stewart
N ON RESIDENTIAL WELL CONSTRUCTION RECORD 4 et
North Carolina Department of Environment and Natural Resources- Division of Water Quality3 �!
P
WELL CONTRACTOR CERTIFICATION # 3094-A
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
NC 28428
State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-A3
3. WELL USE (Check One Box) Monitoring ri Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 3/13/2012
4. WELL LOCATION:
Proposed Wilminaton River Front Marina
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Han
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley ❑ Flat7 Ridge ❑ Other
KccISTCD 34 i"AAA&AAAAAAAAI CL R OR 34124'7\3' a 7 CC
KNMF F$TCD 77 i^"^^St"^"^"^^^! CL R OR-�'?.'951335 CC
Latitude/longitude source: VGPS :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.)
River Front Marina
Facility Name
Nutt St_
Facility ID# (if applicable)
Street Address
Wilmington NC 28401
City or Town State Zip Code
Adam Lisk
Contact Name
720 North Third Street Ste. 202
Mailing Address
Wilminaton NC 28401
City or Town State Zip Code
( 910 n 251-6160
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 44"
b. DOES WELL REPLACE EXISTING WELL? YES p NO q/
c. WATER LEVEL Below Top of Casing: NA
(Use "+" if Above Top of Casing)
FT.
d. TOP OF CASING IS 0.5 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): NA METHOD OF TEST NA
f. DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
Bottom
Bottom
Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top +0.5 Bottom -0.5 Ft. 2" S 40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top . 0 Bottom -0.25 Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top -0.5 Bottom -3.75 Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
Method
Diameter Slot Size Material
: 10. SAND/GRAVEL PACK:
Depth
Top -0.25 Bottom -3.75 Ft.
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
•
0 / -4
•
•
•
•
/
1
• 12. REMARKS:
Size
in.
i:NJ
Formation Description
Disturbed Sediment and Debris
RECEIVErjI 'En
•
Infnr natbn Pfoco3sing Unit
APR
2W2ti 12
• DID/CIA
• 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 TO THE WELL OWNER.
gbWiettikr 5."( 3/26/201
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
: Ronald E Stewart
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
ubmit within 30 days of completion to: Division of Water Quali
17 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-lb
Rev. 1/08