403716_Well Construction - GW1_20120315

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1. WELL CONTRACTOR:
Bobbie Fowler
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2869
Well Contractor (Individual) Name
Mid -Atlantic Drillina, Inc
Well Contractor Company Name
PO Box 315
Street Address
Carolina Beach
City or Town
(910 ) 458-5020
NC 28428
State Zip Code
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-SV7
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
Irrigationo Other sf (list use) Soil Vapor Monitorina
DATE DRILLED 12-28-2011
4. WELL LOCATION:
602 Sunnyvale Dr. 28412
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY NHC
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope DValley elat ❑Ridge ❑Other
K@R$TCD 34 jAAAA&AAAAAAAAI CL R OR 34 476223AAAA CC
14\IMF F$TCD 77 i^AAAVAAAAAAA! CL R OR 717;'93527AAAA CC
Latitude/longitude source: Q�PS ❑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 Packing and Dratina
Facility Name Facility ID# (if applicable)
602 Sunnyvale Drive
Street Address
Wilminaton NC 28412
City or Town State Zip Code
Steve Tyler
Contact Name
804 Porters Neck Road
Mailing Address
Wilminaton NC 28411
City or Town State Zip Code
t 910,16 508-8833
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 7'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c. WATER LEVEL Below Top of Casing: 5 FT.
(Use "+" if Above Top of Casing)
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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
g. WATER ZONES (depth):
Top 5 Bottom 7 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top 0
Bottom 2
Thickness/
Diameter Weight Material
Ft. 2" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
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
Top 1 Bottom 7 Ft. #2
Top Bottom Ft.
: Top Bottom Ft.
Material
torpedo
: 11. DRILLING LOG
Top Bottom Formation Description
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12. REMARKS:
See attached
vdti\R 5 ?AC
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 PFjOVIDED TO THE WELL OWNER.
1-11-201
SIGNIOR OF CERTIFIE W ONTRACTOR DATE
Bobbie Fowler
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit within 30 days of completion to: Division of Water:Qual inf ormation Processing,
y
17 Mail Service Center, Raleigh, NC. 27699-161, Phone : {919) 807-6300
Form GW-lb
Rev. 1/08