410439_Well Construction - GW1_20130211

NONRESIDENTIAL 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
City or Town State
(919 ) 644-2814
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) M W-104
27278
Zip Code
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑
Industrial/Commercial 0 Agricultural ❑ Recovery ❑ Injection d
Irrigation❑ Other 0 (list use)
DATE DRILLED 10/15/12
4. WELL LOCATION:
Quality Drive
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
11, n .4 ei
: 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 5.0 Ft. 2" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
: Top 0 Bottom 1.0 Ft. Portland
Top 1.0 Bottom 3.0 Ft. Bentonite
Top Bottom Ft.
Method
Tremie
Tremie
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 15.0 Ft. 2 in. .006 in. PVC
Top
CITY: Navassa COUNTY Brunswick : Top
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 34 "DMS OR 34.25650703 DD
LONGITUDE 77 " DMS OR 77.98623561 DD
Latitude/longitude source: ❑GPS (71Topographic 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 Che
Facility Name
Quality Drive
Facility ID# (if applicable)
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: 15.0'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO GI
c. WATER LEVEL Below Top of Casing: $ 0
(Use "+" if Above Top of Casing)
FT.
Bottom Ft. in.
Bottom Ft. in.
in.
in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 3.0 Bottom 15.0 Ft. #0 Sand
•
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
/ No samples taken
•
• /
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
12. REMARKS:
E C 5 2012'
irF
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC4fED'4N,-ACG R,pA4NCEJWITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY Or THIS r-•
RECORD HAS BEEN DROVIDED TO THE WELL OWNER.
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SIGNATURE OF CERTIFIED WELL CONTROGT'„9
Kevin White h•te `;;
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PRINTED NAME OF PERSON CONSTRUCTING'THmai' ya I L r
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