410437_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
City or Town
(919 ) 644-2814
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC
State
27278
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-101
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection rof
IrrigationD Other ❑ (list use)
DATE DRILLED 10/10/12
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
LONGITUDE 77
" DMS oR 34.25650703 DD
DMS OR 77.98623561 DD
Latitude/longitude source: ❑GPS Q 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.)
Former Estech General Cho
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 15.0 Ft. 1.5" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 11.0 Ft. Portland
Method
Tremie
Top 11.0 Bottom 13.0 Ft. Bentonite Tremie
Top Bottom Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top 15.0 Bottom 20.0 Ft. 1.5 in .006 in. PVC
Top Bottom
Top Bottom
: 10. SAND/GRAVEL PACK:
Depth
: Top 13.0 Bottom 20.0
Top
: Top
Bottom
Bottom
: 11. DRILLING LOG
: Top Bottom
•
Facility Name Facility ID# (if applicable) ••
/
Quality Drive =•
•
•
/
•
Street Address
Navassa
City or Town
NC 28404
State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20.0'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO qI
c. WATER LEVEL Below Top of Casing: 18.0
(Use "+" if Above Top of Casing)
FT.
•
/
12. REMARKS:
Ft. in. in.
Ft. in. in.
Size
Ft. #0
Ft.
Ft.
Material
Sand
Formation Description
No samples taken
Uhr,. i4 4'11 .2 OP
i . 'K°,,}f4'ti fr S•,-"' i b Ir t-
▪ I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE �IVITH''
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OE,THIS
N PROVIDED TO THE WELL OWNER.
• RECORD HAS B
SIGNA'TURE OF CERTIFIED WELL CONTRACTOR
Kevin White
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
11 pA`�
e
Submit within 30 days of completion to: Division of Water Quality Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09

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