404302_Well Construction - GW1_20120416

1. WELL CONTRACTOR:
Kirk McDonald
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4110-B
d. TOP OF CASING IS -0, 4 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): METHOD OF TEST'
f. DISINFECTION: Type Amount
: g. WATER ZONES (depth):
Well Contractor (Individual) Name
Practical Environmental Solutions
Well Contractor Company Name
P.O. Box 12590
Street Address
Wilmington NC 28405
City or Town State Zip Code
(910 ) 790-8265
Area code Phone number
• 2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# ACt
OTHER ASSOCIATED PERMIT#(if applicable) 404,
SITE WELL ID #(if applicable) N J' 1
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 3 I - 12
4. WELL LOCATI N:
N q OY4 S
(Street. Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: (141 t - COUNTY eu.) re'r
TOPOGRAPHIC / ND. SETTING: (check appropriate box)
❑ Slope ❑Valley Er at ❑Ridge DOther
LATITUDE 343� ° 2 ' 4ev- DMS OR 3X.XXXXXXXXX DD
LONGITUDES )? ° 6' 5.-<2 " DMS OR 7x.xxxxxxxxx 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.)
-.;5res't - 1169
Facility N me / Facility ID# (if applicable)
/09 hyr\ecr ti5 ..)(*u."6
Street iydress
LC) tj
ft. 2Bkv3
City or Tow
r
5(7L,_,,14/t r...� t 5
ontactla e
1/09 Hi' it s
State Zip Code
Mailing Address.
(.0 L ikt( '4*Yk /03
City or Town State
( )/O) Sl 2 -T32O
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
tg
b. DOES WELL REPLACE EXISTING WELL? YES ❑
Zip Code
NO
c. WATER LEVEL Below Top of Casing: /15'
FT.
(Use "+" if Above Top of Casing)
: Top Bottom
Top Bottom
: Top Bottom
: 7. CASING: Depth
Top 0 Bottom
Top Bottom
Top Bottom
: 8. GROUT:
Top
: Top
• Top
9. SCREEN:
: Top__
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft. 5c 114o P! c
Ft.
Ft.
Depth Material,
Bottom f Ft. Cat C .r
Bottom .. Ft. LeRtitvo. ;7/it'
Bottom Ft.
Depth
Bottom
Method
Pour
c.r r
Diameter Slot Size Material
Ft. 2 in. 0. 0l in. PVC -
Ft. in. in.
Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top 7 Bottom i g Ft.
: Top 2 Bottom 9- Ft. AO( ?a, c
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / . It
!1 /
/
/
/
/
12. REMARKS:
Size
Materi 1
�
Formation Desc iption
4. if Saks
u) 6'4 4.te f...xad
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRid
: 15A NCAC 2C WELL CONST ,UCTION STANDARDS, I(D
: RECORD AS BEEN P U ,EDT TH WE
•
SIGNATURE/OPCRTIFIE
.
WELL CONTF
- rari
°oc
1toc.v,r\NtrsoG
/ACCORDANCE WITH
'COPY OF THIS
TOR ?.
\`' H7'
PRINTED NAME OF PERSON CONSTRUCTING THE \ELL A p p 1 6 ZOIZ
n
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form 2GW/09 �-1 ___-
b