413980_Well Construction - GW1_20130610

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3322-A
1. WELL CONTRACTOR:
Lawrence D. Opper
Well Contractor (Individual) Name
Regional Probing Services
Well Contractor Company Name
STREET ADDRESS PO Box 1161
Wake Forest, NC 27588
City or Town State
(919 570-5588
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-3R
STATE WELL PERMITCif applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) -Monitoring E] Municipal/Public 0
Industrial/Commercial 0 Agricultural D Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 4/25/2013
TIME COMPLETED N/A
3. WELL LOCATION:
CITY: Newport
5338 US Hwy 70E
AMO PM
COUNTY Carteret
(Street Name, Numbers, Community; Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley g Flat El Ridge 0 Other
(check appropriate box)
LATITUDE 3 N34.742415
LONGITUDE W76.820004
May be in degrees, .
minutes, seconds or
in a decimal, format
Latitude/longitude source: 0 GPS. D Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY Fox Harbor #14
STREET ADDRESS 5338 US Hwy 70E
Newport, . NC 28570
City or Town State . Zip Code
CONTACT PERSON NCDENR DWM UST Section
MAILING ADDRESS 1637 Mail Service Center, Raleigh, NC
Raleigh, NC
27699
City or Town State Zip Code
( 919 707-8200
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 13'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 12
c. WATER LEVEL Below Top of Casing: —5 - FT.
(Use "+" if Above Top of Casing)
I 3 2 0
d. TOP OF CASING IS .10
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): METHOD OF TEST
f. DISINFECTION: Type NA
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth ,Qiameter
From 0 To 5 Ft. 4
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From
0 To Ft. 3 cement pour
From 3 T 4 Ft. bentonite pour
From To Ft.
Amount
TI
EiaI
8. SCREEN: Depth Diameter Slot Size Material
From 5 To 13 Ft.2 in. .010 in. PVC
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
Ft. #2 Sand
From 4 To 13
From To Ft.
From To Ft.
10. DRILLING LOG
From To - Formation Description
0-13' siltv sand
11. REMARKS:
-IUN 0 2013
BY- • -
WAIER QUALVY .GTION
441ORMYI0N PROCESSING UM r
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR HAS EN PROVIDED TO THE WELL OWNER.
SIG
ATURE
AU
RTIFIED WELL CONTRACTOR .DATE
PRINTED NAME OF PERS*); ' ONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
•
Form GW-lb
Rey-. 7/05