404217_Well Construction - GW1_20120416

R ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2482
1. WELL CONTRACTOR:
Scott Skipper
Well contractor (Individual) Name.
Skippers Well Drilling & Pump Service, Inc.
Well Contractor Company Name
107 Oakland Avenue
Street Address
Leland
NC 28451
City or Town State
910 3712770
Area Code Phone Number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
SITE WELL ID# (if applicable)
Zip Code
3. WELL USE (Check Applicable Box): Monitoring well
DATE DRILLED 03/12/201 2
TIME COMPLETED
4. WELL LOCATION:
City: Wilmington
AMC
M[1]
County New Hanover
(Street Name, Numbers, Community, subdivision, Lot Nol, Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑Valley
LATITUDE N34°
Flats Ridge Other
14 . 814
LONGITUDE W077° 49 . 672
Latitude/longitude source: pziGPS Topographic map
(location of well must be shown on a USGS topo map and attached to
this form if not using GPS)
5. WELL OWNER
Village at Mayfaire
Owner Name
Infiltration Area by roadside
▪ g. WATER ZONES (depth):
▪ Top ___ Bottom Top
▪ Top Bottom Top
. Top __ Bottom Top
7. CASING: Depth
▪ Top 0 Bottoms
• Top Bottom Ft.
Top Bottom Ft.
Street Address
City or Town
( 910 )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 7
b. DOES WELL REPLACE EXISTING WELL? YES El NOD.
State Zip Code
8. GROUT: Depth
Top + Bottom
Top - Bottom 3 Ft. portiand
Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
Ft. 2 sch 40 PVC
Material Method
4 Ft. bentonite
Pour
Pour
9. SCREEN:Depth Diameter Slot Size Material
Top 5 Bottom 7 Ft. 2 in. 18 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
• 10. SAND/GRAVEL PACK:
Depth
Top 4 Bottom
. Top
. Top
c. WATER LEVEL Below top of Casing: 5 FT
(Use "+" if Above Top of Casing)
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.
e.YIELD (gpm): 5-7 METHOD OF TEST
f. DISINFECTION: Type HTH Amount cup
Size Material
7 Ft. #2 Southern Products
Bottom Ft.
Bottom Ft.
11. DRILLING LOG
Top / Bottom
/ 3 Sand ail
3 / 4 Clay 1 ili
4 / 7 Sand
/
/
12. Remarks:
,„ , -, it , \
ion 'cr: ,iii , ,,
i` . ibr
Formato Desdip:
PR 4
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intmetion Processing kkilt
GWGf80G
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 9WNER.
,tz-t-t__
SIGNATURE OF CERTIFIED WE'LL CONTRACTOR
-t \ ��
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1.:
7
DATE
Submit within 30 clays of completion to" Division of Water Quality - . information Processing Form GW-la
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone] Rev. 2/09