HomeMy WebLinkAbout410441_Well Construction - GW1_20130211NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2973
1. WELL CONTRACTOR:
Kevin White
Well Contractor (Individual) Name
Parratt-Wolff, Inc.
Well Contractor Company Name
501 Millstone Drive
Street Address
Hillsborough NC 27278
City or Town State Zip Code
(919 ) 644-2814
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-109
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection Cy.
Irrigation❑ Other 0 (list use)
DATE DRILLED 10/16/12
4. WELL LOCATION:
Quality Drive
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Navassa COUNTY Brunswick
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley ❑ Flat 0 Ridge ❑ Other _
LATITUDE 34 "DMS OR 34.25650703 DD
LONGITUDE 77 " DMS OR 77.98623561 DD
Latitude/longitude source: D3PS Vjropographic 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.)
Former Estech General Cher
Facility Name Facility ID# (if applicable)
Quality Drive
Street Address
Navassa NC 28404
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 18.0'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO al
c. WATER LEVEL Below Top of Casing: 1 1.0
(Use "+" if Above Top of Casing)
FT.
41Ir) '
:
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
g. WATER ZONES (depth):
: Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
: Top 0 Bottom 8.0 Ft. 2" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 4.0 Ft. Portland Tremie
Top 4.0 Bottom 6.0 Ft. Bentonite Tremie
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top 8.0 Bottom 18.0 Ft. 2 in. .006 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
•
Top 6.0 Bottom 18.0 Ft. #0 Sand
Top Bottom Ft.
Top Bottom Ft.
: 11. DRILLING LOG
: Top Bottom Formation Description
•
/ No samples taken
•
/
/
•
12. REMARKS:
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTEDWAteQRQANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECORD HAS BEEPROVIDED TO TH6/WELL OWNER.
• SIGNATURE OF CERTIFIED WELL CONTICT0'.TE':
Kevin White �,
PRINTED NAME OF PERSON CONSTRUCT I IG EELi 2013
Submit within 30 days of completion to: Division of Water .Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : (919) 807-6300
Rev. 2/09
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