410453_Well Construction - GW1_20130211

NONRESIDENTIAL WELL CONSTRUCT
ION RECORD
North Carolina Department 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
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS 0 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
Street Address
Carolina Beach g. WATER ZONES (depth):
N C 28428 ; Top Bottom Top
City or Town State Zip Code
. Top Bottom Top
( 910 ) 458-5020
Top Bottom Top
Bottom
Bottom
Bottom
• Thickness/
; 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# N/A : Top 0 Bottom 4 Ft. 2"
Sch 4( PVC
OTHER ASSOCIATED PERMIT#(if applicable) N/A : Top Bottom Ft.
SITE WELL ID #(if applicable) MW-2 : Top Bottom Ft
3. WELL USE (Check One Box) Monitoring d MunicipaVPublic ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationo Other ❑ (list use)
DATE DRILLED 1 1 /16/2012
4. WELL LOCATION:
6747 Market Street
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zia Code) /
• New l- cs Ife
CITY: Wilminaton COUNTY N.H.0
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VFlat DRidge ❑ Other
LATITUDE 34 U 15 ' 33.2500 DD
LONGITUDE 77
DD
Latitude/longitude 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 (Name of the business where the well is located.)
Kelly's Auto Repair N/A
Facility Name Facility ID# (if applicable)
6747 Market Street
Street Address
Wilminaton NC 28405
City or Town State Zip Code
Bill Henderson
" DMS OR
50 , 8.8600 " DMS OR
Contact Name
1117 Military Cutoff Drive
Mailing Address
Wilminaton NC 28405
City or Town State Zip Code
( 910,E 509-3909
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 29
b. DOES WELL REPLACE EXISTING WELL? YES q/ NO ❑
c. WATER LEVEL Below Top of Casing: 10.97 FT.
(Use "+" if Above Top of Casing)
•
•
•
•
•
•
•
•
:
•
•
•
•
•
8. GROUT: Depth
: Top 1 Bottom 3
Material
Ft. bentonite
Top 0 Bottom 1 Ft. concrete
Top Bottom Ft.
Method
pour
pour
9. SCREEN: Depth Diameter Slot Size Material
Top 4 Bottom 29 Ft. 2 in. 0.01 in. pvc
Top Bottom Ft. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top 3 Bottom 29 Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0
2
10
l2
/10
129
/
/
12. REMARKS:
in.
Size Material
#2 torpedo sand
natural pack
Formation Description
Dark brown fine & medium sand
Yellowish tan clayey fine sand
Gray fine and medium sand
DEC ' 2ui2
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS r" ` ''"``
REfJRD- IAA BEEN PROVI R ED TO THE WELL OWNER. ,.. -,7 v:• �, ', ;'
• S NATURE OF E 3
11 /18/12
RTIFIED CONTRALTOEB A 1
: Bobbie Fowler
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Wateruali
1617 Mail Service Center, NC 2 � � - Information Processing,
Raleigh,7699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09