414382_Well Construction - GW1_20130701

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division pf Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
9088 North Field Dr
Street Address
Fort Mill
sc 29707
City or Town State Zip Code
( ) [phone]
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(it applicable)
SITE WELL ID #(if applicable) 10
3. WELL USE (Check One Box) Monitoring gg Municipal/Public 0
Industrial/Commercial 0 Agricultural D Recovery 0 Injection 0
IrrlgationD Other 0 (list use)
DATE DRILLED 6/13/13
4. WELL LOCATION:
267 Western Boulevard Jacksonville, NC
(Street Name, Numbers. Community, Subdivision, Lot No.. Parcel, Zip Code)
-CITY: __._.:..
COUNTY 0 fDbr)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope DValley ❑Flat DRidge ❑Other
LATITUDE 34.757805 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE -77.381668 "DMS OR 7x. XXXXXXXXX DD
Latitude/longitude source: COPS ['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.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town
State Zip Code
Environmental Services and solutions
Contact Name
PO Box 12055
Mailing Address
Wilmington
NC 28405
City or Town State Zip Code
( 910 ) 470-7066
Area code Phone number
AIL'.
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES D NO Ni
c. WATER LEVEL Below Top of Casing: FT.
(Use "+^ if Above Top of Casing)
3476
414382
d. TOP OF CASING IS 0 FT. Above Land Surface*
"Top of casing terminated atlor 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 2 Bottom 12 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 2 Bottom 12 Ft. 2" 40 pvc
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 1 Ft. Portland
Top Bottom. Ft.
Top Bottom Ft.
Method
pour
9. SCREEN: Depth Diameter Slot Size Material
Top 2 Bottom
Top Bottom Ft. in. in.
Top„ BottomFt. m
12 Ft. 2 in. 010
10. SAND/GRAVEL PACK:
Depth Size
Top 1.5 Bottom 12 Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / 12
/
in. pvc
Material
sand
Formation Description
sand
12. REMARKS:.
shallow water table 2'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCKCECTSVELIZONSIHULi UWSJANDAHUS.ENUIHAIA LO!'Y1k_In ___.__
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SI 1'�
//6/17/2013
0SERTiriED WELL CONTRACTOR DATE
Randy Hoffman
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