410818_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) USTTE/SW- MWO8
3. WELL USE (Check One Box): Monitoring ® Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection ❑
Irrigation ❑ Other ❑ (list use) -
DATE DRILLED: JUIv 13, 2012
4. WELL LOCATION:
Rapid Refueler, New River MCAS
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Cade)
CITY: Jacksonville COUNTY: Onslow
TOPOGRAPHIC / LAND SETTING (check appropriate box)
Ds lope ID Valley IN Flat El Ridge ❑Other:
LATITUDE' 34.711068 DE)
LONGITUDE: 77.447989 DD•
Latitude/longitude source: ® GPS ❑ Topo. map
(Location of well must be shown on a USGS topo map and
attached to this form it not using a GPS.)
6. FACILITY (Name of 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
City or Town
Ms. Jenni Provost
NC
State
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: 17.5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing. 12.27 FT
(Use '4" if Above Top of Casing)
d. TOP OF CASING IC -0.30 FT Above Land Surface`
• Top of casing terminated atter below land surface may require
a variance in accordance with 15A NCAC 2C.011e.
e. YIELD (gpm): WA METHOD OF TEST: WA
f. DISINFECTION: Type N/A Amount: WA
g. WATER ZONES (depth):
Top
Top
Top
7. CASING:
Bottom
Bottom
Bottom
Top
Top
Top
Bottom
Bottom
Bottom
Thickness/
Depth Diameter Weight Material
Top 0.3 Bottom 7.5 Ft. 2 in. Sch. 40 PVC
Top Bottom Ft. in.
Top Bottom Ft. in.
8. GROUT: Depth Material Method
Top Bottom Ft.
Top 3.5 Bottom 5.5 Ft. Bent. Pellets Surface Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 7.5 Bottom 17.5 Ft. 2 in. Slot .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size . Material
Top 5 5 Bottom 17.5 Ft. #2 Medium Torpedo Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
SEE
ATTACHED
12. REMARKS:
r
c,4InJ`177:' ,S
N
FEB ®W�013
I DO HEREBY CERTIFY THAT THIS WELL WA5CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SI MATURE OF CERTIFIED WELL C1.+TRACTOR
D.T. Chalmers, Jr.
PRINTED NAME OF PF(C ! Ic WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, 1 s i• ^~ k-
1617 Mail Service Center, Raleigh, NC 27699-1617, Phone No. [phone] �AN E• �1 '!�!
/-1-20/3
DATE
Modified from
Form GW-lb
Rev. 2/09
infnrmatinn Prrutessino UM!..