411115_Well Construction - GW1_20130204

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Deparhnent of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2869-A
1. WELL CONTRACTOR:
Bobbie Fowler
Well Contractor (Individual) Name
Mid -Atlantic Drilling Inc.
Well Contractor Company Name
PO Box 315
Street Address
Carolina Beach
NC 28428
City or Town State Zip Code
(910 ) 458-5020
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #af applicable) MW-2
3. WELL USE (Check One Box) Monitoring d Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
IrrigationD Other 0 (list use)
DATE DRILLED 12/19/2012
4. WELL LOCATION:
1040 Topsail Greens Drive
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Hamotstead dOUNTY Pender
TOPOGRAPHIC / LAND�/SETTING: (check appropriate box)
Se ❑Slope DValley Flat ❑Ridge ❑Other
KOFSTCD 34 1,24AnegaaeOAnnl CL R OR AAAAAAAAAAAAA CC
IQJMFFSTCD77 IAa7A8tas*80D"AI CL ROR AAAAAAAAAAAAA CC
Latitude/longitude source: BPS IZ(ropographic 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.)
Topsail Greens Golf Course N/A
Facility Name Facility ID# (if applicable)
1040 Tonsail Greens Drive
Street Address
Hamnstead NC 28443
City or Town State Zip Code
Bill Henderson
Contact Name
1117 Military Cutoff Road
Mailing Address
Wilmington NC 28405
City or Town State Zip Code
( 9101 509-3909
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 0
c. WATER LEVEL Below Top of Casing: 4 18
(Use "+" if Above Top of Casing)
FT.
411115
d. TOP OF CASING IS 2 60 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 Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight
Top +2.6 Bottom 2 Ft. 2" Sch 4C
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 1 Bottom 2
Top 0 Bottom 1
Material
Ft. bentonite
Material
PVC
Method
Dour
Ft. concrete DOUr
Top Bottom FI.
9. SCREEN: Depth Diameter Slot Size Material
Top 2 Bottom 12 Ft. 2 in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth
0.01 in. pvC
in.
in.
Size Material
Top 2 Bottom 12 Ft. #2 torpedo sand
Top Bottom Ft. natural pack
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /1
1 / 10
10 / 12
12. REMARKS:
Formation Description
Brown silty fine sand
Gray fine and medium sand
Yellowish tan silty fine and
medium sand
I DO HEREBY CERTIFY THAT THIS
15A NCAC 2C, WELL CONSTRUCT
REC•.SI HAS EN ROVDDEDT
Iy�
OF CERTIF
Bobbie Fowler
L WAS CONSTRUCTED IN ACCORDANCE WITH
ANDARDS, AND THAT A COPY OF THIS
WELLOWN
12/20/12
ONTRAOTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
p
iol rF lTIr
Submit within 30 days of completion to: Division of Water Qualityin m Gw-1b
Y p - Information Processing, / b 0 2u v 1/08
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
'i:1¢O.rrtenon Procf.sslnn Unit