406549_Well Construction - GW1_20120711

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
rl 4 CI
WELL CONTRACTOR CERTIFICATION # 4108-B
- N
1. WELL CONTRACTOR:
William Kicker
Well Contractor (Individual) Name
Mad Dawa, Inc.
Well Contractor Company Name
1006 Camp Creek Rd
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC
State
28080
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) AS-9
3. WELL USE (Check One Box) Monitoring (it Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 Wrightsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Hanovo
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope ❑ Valley itFlat ❑ Ridge ❑ Other
LATITUDE 34 .12 ' 702.0000 DMS OR 3X.xxxxxxxxx DD
LONGITUDE 77 ° 51 ' 972.0000 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 3PS ❑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.)
Formes Scotchman #182
Facility Name Facility iD# (if applicable)
520Q Wrightsville Ave
Street Address
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
: f. DISINFECTION: Type NIA 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 45' Ft. 2" Sch40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 40', Ft. Portland Trimmie
Top 40'_ Bottom 43' Ft. Bentonite Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 45' Bottom 50' Ft. 2" in. .010 in. PVC
Top Bottom Ft. in. in.
: Top Bottom Ft. . in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
▪ Top 43' Bottom 50' Ft. #2 Silica
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
• • 0 / 50' Silty Sand
/
/
Wilminaton NC 28403 I
City or Town State Zip Code : /
Brvan Lievre
Contact Name
P .O. Box 12055
Mailing Address •
♦
Wilmiriatort SIC 284Q5
City or Town State Zip Code
( 910,S 932-3050
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 50'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO r/
c. WATER LEVEL Below Top of Casing: 8' FT.
(Use "+" if Above Top of Casing)
•
/
/
/
12. REMARKS:
11
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION TANDAR iS, AND THAT A COPY OF THIS
: RECORD HAS BEEN PROVIDED TO TH NE
SIGNATURE OF C TI ►r•-D WELL CO
iie
PRINTED NAME OF PER llCONSTR CTING HE WELL
6- tet- i;
RACTOR DATE
Submit withii<: 30 days of completion to: Division of Water Quality - informlation Processing,
1617 Mail Service Center, Raleigh, NC 27699*161, Phone [phone]
Form GW-lb
Rev. 2/09