411116_Well Construction - GW1_20130204

OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW- 1
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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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
Street Address
Carolina Beach
City or Town
(910 ) 458-5020
Area code Phone number
NC
State
28428
Zip Code
411116
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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
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
2. WELL INFORMATION: Thickness/
7. CASING: Depth Diameter Weight
WELL CONSTRUCTION PERMIT# N/A : Top 0 Bottom 8 Ft. 2" Sch 4C
Bottom
Bottom
Bottom
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 12/18/2012
4. WELL LOCATION:
510 Village Road
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Leland COUNTY Brunswick
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley i(Flat 0 Ridge ❑ Other
LATITUDE 34 ° 14 28.7500 "DMS OR
DD
LONGITUDE 78 ° o ' 37.9700 " DMS OR DD
Latitude/longitude source: DGPS ❑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.)
Crescent State Bank Leland Pronrty
Facility ID# (if applicable)
Facility Name
510 Villaae Road
Street Address
Leland NC 28451
City or Town State Zip Code
Keith Betts
Contact Name
1508 Military Cutoff Road
Mailing Address
Wilmington NC
City or Town 28405
State Zip Code
( 910,6 344-2265
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 18
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
c. WATER LEVEL Below Top of Casing: 1 1.1 0 FT.
(Use "+" if Above Top of Casing)
•
•
•
•
Top
Top
Bottom Ft.
Bottom Ft.
8. GROUT: Depth Material
Top 3 Bottom 6 Ft. bentonite
Top 0 Bottom 3 Ft. concrete
Top Bottom Ft.
Material
PVC
Method
pour
pour
▪ 9. SCREEN: Depth Diameter Slot Size Material
Top 8 Bottom 18 Ft. 2 in. 0.01 in. pvc
• Top Bottom Ft.
Top Bottom Ft.
•
•
in. in.
in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 6 Bottom 18 Ft. #2 torpedo sand
Top Bottom Ft. natural pack
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /2
2 /4
4 /6
6 /16
16 / 18
12. REMARKS:
Formation Description
Brown medium sand
Tan medium sand
Bluish gray sandy clay
Tannish gray medium sand
Yellowish orange fine and
medium sand
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONS LtTED IN .
ACCORDANCE WITH ..--
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, A Q_ HAT A COPX.oF--THrS—
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CON 12/20/12
TRACTOR DATE
Bobbie Fowler
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality•
h NC 276 Information Processing,
1617 Mail Service Center, Raleigh, , 99-161,:Phone : [phone]
Rev. 2/09
2aJN2013