414100_Well Construction - GW1_20130617

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ofEnvironrnent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2593
1. WELL CONTRACTOR:
Rich Lemi re
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
9088 NORTHFIELD DR
Street Address
FORTMILL
SC 29707
City or Town
__...) [phone]
State
Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#Of applicable)..
SITE WELL ID #(if applicable) MW-2
3. WELL USE (Check One Box) Monitoring a Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
IrrigationD Other 0 (list 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)
Slope :Walley one o Ridge Daher
LATITUDE 34.314806 DMS OR 3x.XXXXXXXXX DD
LONGITUDE -79.033162 " DMS OR 7x.xxxxxxxxx DO
Latitude/longitude source: ( GPS Dropographic 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-2
Facility Name Facility ID# (if applicable)
945 MAIN STREET
Street Address
FAIR BLUFF
City or Town
AUSTIN HEWITT
NC
State Zip Code
Contact Name
7900-D STEVENS MILL RD #120
Mailing Address
MATTHEWS
NC 28104
City or Town
( 704 ) 877-3541
State . Zip Code
Area code Phone number
6. WELL -DETAILS: --- - - -
a. TOTAL DEPTH: 9
b. DOES WELL REPLACE EXISTING WELL? YES o NO IC
c. WATER LEVEL Below Top of Casing: 6
(Use `'+r if Above Top of Casing)
FT.
414100
d. TOP OF CASING IS 0 FT. Above Land Surface*
*Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C ,0118.
: e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
: Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
: Top 0 Bottom 4 Ft. 2
Top Bottom Ft.
Top Bottom Ft.
8_ GROUT: Depth Material
: Top 0 Bottom 3 Ft. PORTLAND
Thickness/
Weight Material
SCH40 PVC
Top Bottom Ft.
Top Bottom, Ft.
9. SCREEN: Depth
Method
POURED
Diameter Slot Size Material
Top 4 .. Bottom 9 Ft. 2 . in.
•
Top Bottom Ft. in.
Top Bottom Ft, in.
.010 in. PVC
in.
• 10. SAND/GRAVEL PACK:
Depth Size Material
Top 3.5 Bottom 9 Ft. # 2 SAND
Top Bottom Ft.
Top, Bottom Ft.
: 11. DRILLING LOG
Top Bottom
•
0 1 9
1
1
1
1
Formation Description
SAND
JUN I
r ,.
rs
i t CVO' \ OW
iNFORMATIO
12. REMARKS:
• BENTONITE FROM 3.0t-3.5'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A-NCAC 20, WELL CONSTRUCTION-S-TANDARCk-- AND-THAT-A_COPY.0E-TI S_
• RECORD HAS BEEN PROVIDED TO THE WELL -OWNER:-
5/25/2013
• SIGNA'rU . OFt;ERTIr=iED 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]
Forrn GW-lb
Rev. 2/09