414101_Well Construction - GW1_20130617

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2593
1. WELL CONTRACTOR:
Rich Leanire
Well Contractor (Individual) Name
•
•
•
•
414101
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.
SAEDACCO Inc e. YIELD (9Pn'+): METHOD OF TEST
Well Contractor Company Name
9088 NORTHFIELD DR
Street Address
FORTMILL
SC 29707
City or Town
) ...._ (7�041. 507-1922
Area code Phone number
State Zip Code
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #( if applicable) MW-3
3. WELL USE (Check One Box) Monitoring a Municipal/Public 0
Industrial/Commercial p Agricultural C Recovery 0 Injection 0
Irrigationo Other 0 Mist use)
DATE DRILLED 5-23-2013
4. WELL LOCATION:
945 Main Street Fair Bluff, North Carolina
(Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
CITY: FAIR BLUFF
COUNTY COLUMBUS
TOPOGRAPHIC / LAND SETTING: {check appropriate box)
D Slope o Valley Flat o Ridge DOther
LATITUDE 34.314806 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE -79.033162 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: 23PS DTopographic 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.)
GAS STATION
MW-3
Facility Name Facility ID# (if applicable)
945 MAIN STREET
Street Address
FAIR BLUFF
NC
City or Town
AUSTIN HEWITT
State Zip Code
Contact Name
7900-D STEVENS MILL RD #120
Mailing Address
MATTHEWS
NC 28104
City or Town
State Zip Code
( 704 ) 877-3541
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
9
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO N
c. WATER LEVEL Below Top of Casing: 6
(Use "+" if Above Top of Casing)
FT.
f. DISINFECTION: Type Amount
: g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight
Top 0 Bottom 4 Ft, 2 SCH4 0
Top . Bottom Ft.
Top . Bottom Ft.
8. GROUT: Depth Material
: Top 0 Bottom 3 Ft. PORTLAND
A Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Material
PVC
Method
POURED
Diameter Slot Size Material
: Top 4 Bottom Ft. 2 in.
Top Bottom . Ft, in.
: Top.,. ,- ._ Bottom Ft In.
: 10. SAND/GRAVEL PACK:
Depth Size
Top 3.5 Bottom 9 .__ Ft. #2.
Top Bottom Ft.
: Top Bottom Ft.
010 in.
in.
in•
PVC
Material
SAND
: 11. DRILLING LOG
: Top Bottom Formation Description
0 / 9 SAND
/
/
JUN 17 2013
j no
WiRi ER. QUAD t Y Sty 41 t
INFORMATION PROGESStG UNIT
: 12. REMARKS:
: BENTONITE FROM 3.0' -3.5'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
...15A -NCAC 2C. WELL -CONSTRUCTION STANDARDS: AND THAT--A-C-OPY-OF-THls— ---
• RECORD HAS BEEN PROVIDED TO THE WELL OWNER_
5/25/2013
• SIGNA•I�UI Off- i;;ER T IFIEL) WELL CONTRACTOR DATE
RICHY L LEMIRE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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