411114_Well Construction - GW1_20130204

1. WELL CONTRACTOR:
Bobbie Fowler
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2869 A 11
d. TOP OF CASING IS -0.48 FT. Above LBifd-Su1a?e'I 4
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
Well Contractor(Individual) Name
Mid -Atlantic Drilling Inc.
Well Contractor Company Name
PO Box 315
Street Address
Carolina Beach
City or Town
(910 ) 458-5020
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28428
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-1
3. WELL USE (Check One Box) Monitoring Gi Municipal/Public 0
Industrial/Commercial D Agricultural D Recovery D Injection ❑
Irrigation❑ 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: Hamptstead COUNTY Pender
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope DValley V!Flat ❑Ridge DOther
K(r$l$TCD 34 iiNAA&sts190enAAI CL ROR AAAAAAAAAAAAA CC
IWMFI$TCD77 1A3TA&0Aefe01An1 CL ROR AAAAAAAAAAAAA CC
Latitude/longitude source: IGPS VTopographic 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.)
Tonsail 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
Wilminaton NC 28405
City or Town State Zip Code
( 9106 509-3909
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 15 —/
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO tar
c. WATER LEVEL Below Top of Casing: 6 89 FT.
(Use "+" if Above Top of Casing)
Top 4
Top Bottom Ft.
Top Bottom Ft.
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 Material
Top 0 Bottom 5 Ft. 2" Sch 4( PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 2 Bottom 4 Ft. bentonite
Top 0 Bottom 2 Ft. concrete
Top Bottom Ft.
9. SCREEN: Depth
Top. 5 Bottom 15
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Bottom 15
11. DRILLING LOG
Top Bottom
0 /1
1 / 15
15 /16
/
12. REMARKS:
Method
Dour
pour
Diameter Slot Size Material
Ft. 2 in. 0.01 in. INC
Ft. in. in.
Ft. in. in.
Size Material
Ft. #2 torpedo sand
natural pack
Formation Description
Brown silty fine and medium sanc
Gray fine and medium sand
Bluish Gray clayey fine sand
FEB 6t2013
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL TRUCTION STANDARDS, AND THAT A COPY OF THIS
RS RD HA BEEN THE WEIL OWNER.
ATURE
12/20/12
R '-• ELL CONTRACTOR DATE
Bobbie Fowler
PRINTED NAME OF PERSON CONSTRL1f TINE T.H
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
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