403715_Well Construction - GW1_20120315

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2869
1. WELL CONTRACTOR:
Bobbie Fowler
Well Contractor (Individual) Name
Mid -Atlantic Drilling, Inc
Well Contractor Company Name
PO Box 315
•
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): N/A METHOD OF TEST N/A
f• . DISINFECTION: Type N/A Amount N/A
Street Address g. WATER ZONES (depth):
Carolina Beach NC 28428 : Top 5 Bottom 7
City or Town State Zip Code
(910 ) 458-5020
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A - On- Site
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-SV6
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other ii(Iist use) Soil Vapor Monitoring
DATE DRILLED 1 2-28-2011
4. WELL LOCATION:
602 Sunnyvale Dr. 28412
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY NHC
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley grFlat 0 Ridge ❑ Other
ICgf-STCD 34 i AAAA&AAAAAAAA! CL R OR 34 47634-AAAA cc
KNMF I$TCD 77 i^^^^&^^^^AAAA1 CL R OR 77 935h3AAAA CC
Latitude/longitude source: WXPS ❑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.)
S&R Packino and Cratina
Facility Name Facility ID# (if applicable)
602 Sunnyvale Drive
Street Address
Wilmington NC 28412
City or Town State Zip Code
Steve Tyler
Contact Name
804 Porters Neck Road
Mailing Address
Wilmington NC 28411
City or Town State Zip Code
91015 508-8833
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 7'
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: 5
(Use "+" if Above Top of Casing)
NO qI
FT.
• kIsaQ
Top
Top
Top Bottom
Bottom Top Bottom
Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 2 Ft. 2" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
i Top .5 Bottom 1 Ft. Bentonite Chi pour
Top 0 Bottom .5 Ft. Grout
Top Bottom Ft.
: 9. SCREEN: Depth Diameter Slot Size Material
: Top 2 Bottom 7 Ft. 2 in. 0.01 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
••
Depth Size Material
Top 1 Bottom 7 Ft. #2 torpedo
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
/ See attached
•
/
:
•
/
12. REMARKS:
BAR 15201?
B.i.lsr!.
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.
1-11-201
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
• Bobbie Fowler
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
uhmit within 30 days of completion to:.. Division of Water Quail
1617 Mail Service Center,Raleigh, NC 27699-161, Phone: (919). 807-630
Form GW-1 b
Rev. 1/08