410819_Well Construction - GW1_20130204

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION #: 4146A
1. WELL CONTRACTOR:
D.T. Chalmers, Jr.
Well Contractor (Individual) Name
CATLIN Engineers and Scientists
Well Contractor Company Name
220 Old Dairy Road
Street Address
Wilmington North Carolina 28405
City or Town State Zip Code
( 910) - 452-5861
Area code - Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT #: N/A
OTHER ASSOCIATED PERMIT # (if applicable): N/A
SITE WELL ID # (if applicable) U STTE/S W- M W 12
3. WELL USE (Check One Box): Monitoring ® Municipal/Public 0
IndustriaVCommercial ❑ Agricultural ❑ Recovery 0 Injection ❑
Irrigation ❑ Other ❑ (list use):
DATE DRILLED: December 19, 2012
4. WELL LOCATION:
Rapid Refueler, New River MCAS,
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Jacksonville COUNTY: Ons!ow
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley ®Flat ❑Ridge ❑Other:
LATITUDE: 34.710843 DO
LONGITUDE 77.447715 DD
Latitude/longitude source: ® GPS ❑ Topo. map
(Location of well must be shown on a USGS Topo map and
attached to this form if not using a GPS.)
5. FACILITY (Name at the business where the well is located.)
N/A N/A
Facility Name Facility ID # (if applicable)
Rapid Refueler, New River MCAS
Street Address
Jacksonville
NC
City or Town State
Ms. Jenni Provost
Zip Code
Contact Name
Attn: I&E/ EMD/ EQB/ PSC Box 20004
Mailing Address
Camp Lejeune NC 28542-0004
City or Town State Zip Code
(910)- 451-5068
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 18
b. DOES WELL REPLACE EXISTING WELL?
YES ❑ NO
c. WATER LEVEL Below Top of Casing: 11 .95 FT
(Use "+" if Above Top of Casing)
AM 1
d. TOP OF CASING IC -0.56 FT. Above Land Surface*
• Top of casing terminated aUor below land surface may require
a variance In accordance with 15A NCAC 2C.0118.
e. YIELD (gpm): WA METHOD OF TEST: WA
f. DISINFECTION: Type WA Amount: WA
g. WATER ZONES (depth):
Top
Top
Top
Bottom
Bottom
Bottom
Top
Top
Top
Bottom
Bottom
Bottom
9
7. CASING: Thickness/
Depth Diameter Weight Material
Top 0.56 Bottom 8 Ft. 2 in. Sch. 40 PVC
Top Bottom Ft. in.
Top Bottom Ft. in.
8. GROUT:
Depth Material Method
Top Bottom Ft.
Top 4 Bottom 6 Ft. Bent. Pellets Surface Pour
Top Bottom Ft.
9. SCREEN:
Depth Diameter Slot Size Material
Top 8 Bottom 18 FL 2 in. Slot .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 6 Bottom 18 Ft. #2 Medium Torpedo Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
/
SEE
ATTACHED
1G
12. REMARKS:
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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 PROVIDED TO THE WELL OWNER.
S
r4TURE F ERTIFIEDED WELL CONYRACTOR
D.T. Chalmers, Jr.
/- 2-70/3
DATE
PRINTED NAME OF PERgf:�IYdELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, III
1617 Mall Service Center, Raleigh, NC 27699-1617, Phone No. [phone]
JAN M 8 loll
information Processing Unit
Modified from
Form GW-lb
Rev. 2/09