403723_Well Construction - GW1_20120315

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2540-A
1. WELL CONTRACTOR:
Jeffrey A Stewart
Well Contractor (Individual) Name
Mid -Atlantic Drilling, Inc
Well Contractor Company Name
PO Box315
Street Address
d. TOP OF CASING IS 2 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):
Carolina Beach NC 28428 : Top 5 Bottom 7 Top Bottom
City or Town State Zip Code : Top Bottom Top Bottom
Top Bottom Top Bottom
Area code Phone number
2. WELL INFORMATION: : 7. CASING: Depth Diameter
WELL CONSTRUCTION PERMIT# N/A - On- Site i Top 0 Bottom 3 Ft. 0.8 sch10( PVC
(910 ) 458-5020
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) EW-8
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery (Injection ❑
IrrigationD Other ❑ (list use)
DATE DRILLED 3/2/2012
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 [Valley urFlat ❑Ridge ❑Other
LATITUDE 34 " DMS OR 34.1762031
LONGITUDE 77 " DMS OR 77.937583
DD
DD
Latitude/longitude source: 3GPS [Topographic reap
(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 Crating
Facility Name Facility ID# (if applicable)
602 Sunnyvale Drive
Street Address
Wilminaton NC 28412
City or Town State Zip Code :
Steve Tvler
Thickness/
Weight Material
Top 6 Bottom 7 Ft. 0.8 sch 10( PVC
Top Bottom Ft.
8. GROUT: Depth Material Method
Top Bottom Ft.
Top-- Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 3 Bottom 6 Ft. 10 in. 0.10 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 0 Bottom 7 Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0 / 7 Dark olivetfine-medium grained
•
/ sand few fines (SP)
.
Contact Name
804 Porters Neck Road
Mailing Address
Wilminaton
City or Town
( 910 ,fi 508-8833
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 7'
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 5
(Use "+" if Above Top of Casing)
NC 28411•
State Zip Code
NO qI
FT.
/
12. REMARKS:
MAR 1 5 201Z
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
. 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RE • RD HAS BEEN PROVIDED TQ,THE WELL.OWNER.
IFIED
3/7/12
CO TRACTOR DATE
Jeffrey A Stewart
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit within. 30 days of completionto: Division of Water Quail
1617 Maii Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09