413541_Well Construction - GW1_20130528

STATE r,
.“-.•
1 iNLLI UUN 1 RACTOR:
Sean Cropsey
.WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2485
Well contractor (Individual) Name
Skipper's Well Drilling & Pump Service, Inc.
Well Contractor Company Name
107 Oakland Avenue
Street Address
Leland
NC 28451
City or Town State Zip Code
910 3712770
Area Code Phone Number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WP0290794
SITE WELL ID# (if applicable)
3. WELL USE (Check Applicable Box): F
DATE DRILLED 01/17/13
TIME COMPLETED AM Li ME
4. WELL LOCATION:
City: Rocky Point
County New Hanover
• Top 58 Bottom
▪ Top Bottom
▪ Top Bottom
D.
(Street Name, Numbers, Community, subdivision, Lot Nol, Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Esiope Valley
XX
LATITUDE N34U
LONGITUDE lit--7177 ur.
FlatORidge EjOther
Latitude/longitude source: E1GPS EjTopographic map
(location of well must be shown on a USGS topo map and attached to
this form if not using GPS)
5. WELL OWNER
Georgia Scott
Owner Name
18055 NC Hwv 210
Street Address
Rocky Point, NC 28457
City or Town _ State Zip Code
( 910 ) 675-9357
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 78
b. DOES WELL REPLACE EXISTING WELL? YES NOE].
c. WATER LEVEL Below top of Casing: 12 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 2 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 HTH Amount cup
g. WATER ZONES (depth):
78 Top
Top
Top
7. CASING: Depth
Top +2 Bottom 58
Top Bottom
Top Bottom
Diameter
Ft. 2"
Ft.
Ft.
8. GROUT: Depth
Top 0 Bottom 58 Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN:Depth
Top 58 Bottom
Top Bottom
Top Bottom
.1.
Bottom
Bottom
Bottom
Thickness/
Weight Material
pvc
Material Method
Diameter Slot Size Material
78 Ft. 2 in. in. pvc
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom
Top Bottom
Top Bottom
11. DRILLING LOG
Top / Bottom
0/ 10
1 0 / 20
20 / 40
40 / 48
48 / 78
/
12. Remarks:
Size Material
Ft. Southern Products
Ft.
Ft.
clay
Formation Description
sand
Mud (clay)
shells and sand
limestone
MPT -
es.
V VRA t '17 ;a,
47
I DO HEREBY CERTIFY THAT
ACCORDANCE WITH 15A NC
STANDARDS, AND THAT A C 4 , OF THIS RECORD HAS
PROVIDED TO THE WELL OWNEtil'
M' NATURE OF CERTI
IS
TR
CTI
g.)
ED IN
EN
01/17/13
ELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
=
Form GW-la
Rev. 2/09