414383_Well Construction - GW1_20130701

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3476
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#(if applicable)
SITE WELL ID #(If applicable) 11
3. WELL USE (Check One Box) Monitoring 07 Municipal/Public 0
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigationo 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(1`Si 0L4
TOPOGRAPHIC / LAND. SETTING: (check appropriate box)
❑Slope oValley oFlat ❑Ridge L-(Other
LATITUDE 34.757805 "DMS OR 3x.XXXXXXXXX DD
LONGITUDE -77.381668 "DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: £GPS E ropographic 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
( 910 ) 470-7066
Area code Phone number
nETn,E.
State Zip Code
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES 4' NO X
c. WATER LEVEL Below Top of Casing. FT.
(Use `+^ if Above Top of Casing)
114383
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 2 Bottom 12 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 2 Bottom 12 FL2" 40 pvc
Top Bottom Ft.
Top Bottom Ft,
8. GROUT: Depth Material Method
Top 0 Bottom 1 Ft. Portland pour
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 2 Bottom 12 Ft, 2 in. 010 in. pvc
Top Bottom Ft. in, in.
Tope Bottom- Ft. in, in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 1.5 Bottom 12 Ft. #2 sand
Top Bottom_ Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 12 sand
I
d„I N C 4 Y LI ;
12. REMARKS:
shallow water table 2'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
6/17/2013
St!:R'H9 UF'ir CcRiirfED 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-lb
Rev. 2/09