412128_Well Construction - GW1_20130311

4 I 2 I ‘;(1
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION #: 4146A
1. WELL CONTRACTOR:
D.T. Chalmers, Jr.
Well Contractor (Individual) Name
CATLIN Engineers and Scientists
Well Contractor Company Name
220 Old Dairy Road
Street Address
Wilmington North Carolina 28405
City or Town State Zip Code
( 910) - 452-5861
Area code - Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT #: N/A
OTHER ASSOCIATED PERMIT # (if applicable): N/A
SITE WELL ID # (if applicable) GP-1
3. WELL USE (Check One Box): Monitoring ® Municipal/Public 0
IndustriaVCommercial 0 Agricultural 0 Recovery ❑ Injection ❑
Irrigation ❑ Other ❑ (list use).
DATE DRILLED: January 29, 2013
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY: New Hanover
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑ Valley ® Flat ❑ Ridge DOther:
LATITUDE: 34.1828 DD
LONGITUDE. -77.951 DD
Latitude/longitude source: ® GPS 0 Topo. map
(Location of well must be shown on a USGS topo map and
attached to this form if not using a GPS.)
5. FACILITY (Name of the business where the well is located.)
N/A N/A
Facility Name Facility ID # (if applicable)
Street Address
Wilmington
City or Town
NC
State
Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
LI-
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 10
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: FT. : SI('ATURE CIF CERTIFIED WELL CONTRACTOR
,
(Use + if Above Top of Casing)
▪ d. TOP OF CASING IS 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): N/A METHOD OF TEST: N/A
• f. DISINFECTION: Type N/A Amount: N/A
g. WATER ZONES (depth):
• Top Bottom Top Bottom
Top Bottom Top Bottom
• Top Bottom Top Bottom
: 7. CASING: Thickness/
• Depth Diameter Weight Material
Top 0 Bottom 0 Ft. 2 in. Sch. 40 PVC
: Top
• Top
• 8. GROUT: Depth
: Top Bottom
• Top Bottom
Top Bottom Ft.
• 9. SCREEN:
Bottom Ft. in.
Bottom Ft. in.
Ft.
Ft.
Material Method
Depth Diameter Slot Size Material
Top 0 Bottom 10 Ft. 2 in. Slot .010 in. PVC
• Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
•10. SAND/GRAVEL PACK:
Depth Size Material
• Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
• 11. DRILLING LOG
• Top Bottom
/
/
./
/
Formation Description
MAR 11 2013
SEE INFORMATION WATER QUALltY SECTION
'i OEScII tiNI T
-ATTACHED
12. REMARKS:
• I DO HEREBY CERTIFY THAT THIS WELL ''S COBSTRUCTED IN ACCORDANCE WITH
• 15A NCA C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECORD IAS BEEN PROVIDED TO THE WELL OWNER.
: D.T. Chalmers, Jr.
: 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 27699-1617, Phone No. [phone]
2, 6,e.)13
DATE
Modified from
Form GW-1 b
Rev_ MP