413476_Well Construction - GW1_20130513

NONRESIDENTML WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4110--B
1. WELL CONTRACTOR:
Kirk McDonald
Well Contractor (Individual) Name
Practical Environmental Solutions
Well Contractor Company Name
P.O. Box 12590
Street Address
Wilmington
City or Town
(910 ) 790-8265
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
na
NC
State
28405
Zip Code
OTHER ASSOCIATED PERMIT#(if ap iicable) 44
SITE WELL ID #(if
applicable)
( pp )
W -1
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 5- 2
4. WELL LOCATION: 3 60 t Lief
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
# 4�
I - � I � ��y� � ��� COUNTY � CITY: �'
krtr-
TOPOGRAPHIC / LAND SE I 1 ING: (check appropriate box)
DSlope ❑Valley flat ❑ Ridge ❑Other
LATITUDE .311 ° 94. d 65 "DMS OR 3X.xxxxx CXXX DD
LONGITUDE 75 ?? ° Qi ' a 3 3 " DMS OR 7X.XxxXXxxxX DD
Latitudellongitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Nan, of he b, siness where the well is located.)
(Vd-
ts7,13.-
- 3 60g
Facility Name �s Fa 'lity ID# (if applicable)
( 021 ketti-j4redi
St eet A dress
fit. v'1 • t i
NL
City or Town '
.
.l t ,m
ritarNifrje,
ive/
Cootact Name
State Zip Code
Mailing Address
i (ii,tc yv-y,
City or Town
t .� l 33.
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
/✓C
2�
2M-o"
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top 9 of Casing: I 5 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS
4 1 '3 71 7 (3
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 Material
Top 0- Bottom 0 Ft. 2. 5,1140
: Top Bottom Ft.
: Top Bottom Ft.
: 8. GROUT: Depth Material Method
Top 1 0 Bottom i I Ft. be,44,,,k. ,045G, r-
: Top 0 Bottom 1 Ft. Ca4C l sA.Agp, r
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top i li Bottom 2 Ft. in. 0,6 t in.
P V'C
Top Bottom Ft. in. in.
Bottom Ft in. in.
• Top
: 10. SAND/GRAVEL PACK:
Depth
Top II Bottom 2 Ft.
Top I Bottom t 0 Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Descri Lion
Size
2
aterial
V..t
f14 4/
6 1
I / 2
/
/
/
/
/
/
: 12. REMARKS:
MO41 2
rt
.,A�
NF , Tr .i 'c. ``-ESS}° G MP'
I DO HEREBY CERTIFY THAT THIS WELL WA �STRU 5D IN ACCORDANCE WITH
. 15A AC 2C, \NEL CONSTRUCTION ST �� AN HAT A COPY OF THIS
: RE S SRD HAS EE PROVIDED THE
SIGNAf r
OF CERTIFIED WELL CONTRACTOR
DATE
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]
Form GW-1 b
Rev. 2/09