403775_Well Construction - GW1_20120326

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MAR 262012
NONRESIDENTIAL w CT-101sLRECO n
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3423
1. WELL CONTRACTOR:
WILLIAM T. DUGGINS
Well Contractor (Individual) Name
TERRACON CONSULTANTS, INC
Well Contractor Company Name
5240 GREEN'S DAIRY ROAD
Street Address
, RALEIGH
City or Town
(919 ) 873-2211
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
: d. TOP OF CASING IS 3. FT. Above Land Surface*
*Top of casing terminated a or below land surface may require
a variance to accordance with 15A NCAC-2C:O118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
NC 27605 : Top i j. 2 Bottom 3 c
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) EI-201 1--PZ-
3. WELL USE (Check One Box) Monitoring Ci Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection L7
Irrigati- , Tj Other ❑ (list use)
DATE DRILLEI. 11 0? 2012
4. WELL LOCATION:
EAGLE ISLAND
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WILMINGTON
TOPOGRAPHIC / LAND SETTING:
['Slope ❑Valley DFlat ['Ridge
LATITUDE 36 °
LONGITUDE 75 °
Top _ Bottom
Top , Bottom
7. CASING: Depth
Tort.
3' Bottom • Ft.
�
: Top Bottom Ft.
Top Bottom
Top Bottom
Top , Bottom
Thickness/
Diary- er Weight Material
Top Bottom FL
8. GROUT: Depth - Material
: Top 0 Bottom - Ft. Pc C
Top Bottom Ft.,
Top Bottom Ft.
Mithoa
Fre 1'N
9. SCREEN: Depth Diameter Slot Size Material
r1/4/C-
T▪ op 25j Bottom 3r FL 2. in. 0 •1 in.
Top
Bottom Ft.
COUNTY NEW HANOI : Top Bottom Ft.
(check appropriate box)
Other p wt tcit1T
„ DMS OR 3t'ZoD
"DMSOR -1648cD
Latitude/longitude source: MPS ❑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.)
Confined Disnosal Facility N/A
Facility Name Facility ID# (if applicable)
N/A
Street Address
FAGI .F L I A N D
City or Town
/,cCrC)
ont ct NaPCPf
ail ng Ads
WILMINGTflN NC2.6
City or Town State Zip Code
icho,) 5 1 «A°
Area code Phone number
State Zip Code
6. WELL DETAILS: a. TOTAL DEPTH; 75-1
b. DOES WELL REPLACE EXISTING WELL? YES Cl NO tl
c. WATER LEVEL Below Top 9 of Casing: t .7- FT.
(Use "+' if Above Top of Casing)
in. In.
In. , in.
▪ 10. SAND/GRAVEL PACK:
Depth Size Materil
.--Z.- arc
Top- 23 Bottom Ft.,
Top Bottom Ft.
Top Bottom Ft.
: 11. DRILLING LOG
: Top Bottom
�f23
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•
•
•
•
f
1 _
12. REMARKS:
/
/
Formation Description
S/rN��
Sty
MAR 1 5 2.M?
Unit
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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 PRO V TO THE WELL OWNER.
SIGNA
3/12/1
OF t EFTIFIED WELL CONTRAC—TOR DATE
WILLIAM T. DUGGINS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09