403767_Well Construction - GW1_20120326

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
.0 • WELL CONTRACTOR CERTIFICATION # 3423
1. WELL CONTRACTOR:
WILLIAM T. DUGGINS
W_eiLContractor (lndividual)_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:
d. TOP OF CASING IS 2- 1p
1-1
FT. Above Land Surface*
`Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .01 18.
e. YIELD (gpm): NIA METHOD OF TEST NIA
f. DISINFECTION: Type N/A Amount N(t4
g. WAT ZONES (dep ):
NC. 27605, : Top 1 - Bolcom
Stale Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) EI-2011-PZ-
3. WELL USE (Check One Box) Monitoring liMunicipal/Public ❑
Industrial/Commercial D Agricultural 0 Recovery 0 Injection 0
irrigation0 Other D (list use)
DATE DRILLED 111 /2012
WELL CONSTRUCTION PERMIT# N/A : Topi2
: Top
Top
4. WELL LOCATION:
EAGLE ISLAND
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Dlamet r Weight Material
Bottom ZFt. ,i C
Ft.
Ft.
Bottom
Bottom
Depth
Top Bottom r2D
8. GROUT:p
C.
Material
Ft. Pc C-
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter
: Top 15. Bottom Ft., 2 in.
: Top Bottom Ft. In.
CITY: WILMINGTON COUNTY NEW HANCIN4Top. Bottom Ft. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley DFlat DRidge i0ther Elt.t/tit+tl4W4iW
LATITUDE 36 " DMS OR 3120 624 DD
LONGITUDE 75 ° " DMS OR 7-?-',Cli
Latitude/longitude source: {BPS []Topographic map
(location of well must be shown on a USGS topo map aridatfached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Confined Disnosel Facility NIA
Facility Name Facility ID# (if applicable)
N/A
Street Address
_EAGLEISLAND NC
City or Town State Zip Code
__13ef".6,
ontact N a e
lifov
Mail g Ad ress
WILMINGTON NC2.8
City or Town State Zip Code
ilvelque
(eitro.) 25-t
Area code Phone number
6. WELL DETAILS:
4A0
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Li
c. WATER LEVEL Below Top Casing: Casin : k •'" FT.
(Use `f• If Above Top of Casing)
10. SAND/GRAVEL PACK:
Depth
Top ( 3 Bottom 2' Ft.
Method
7refrIz;
Slot Size
�- 1 in.
In.
Material
in.
Size Material J. /
�- C4-
Top Bottom Ft.
: Top .Bottom Ft.
11. DRILLING LOG
Top Bottom
12. REMARKS;
Formation Description
g
\\kis, toto`coaWQ�4100G
• 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 P-OVID• f THE WELL OWNER.
3/1_2/ 12
: SIGNAT e F r• " I i WELL CONTRACTOR 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