413069_Well Construction - GW1_20130422

}VONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2487
1. WELL CONTRACTOR:
Arnold. Chapel
Well Contractor (Individual) Name
Parratt-Wolff, Inc.
Well Contractor Company Name
501 Millstone Drive
Street Address
Hillsborough NC 27278
City or Town State Zip Code
(919 ) 644-2814
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) AS-4
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery D Injection 0
Irrigation❑ Other (list use) Air SDarae
DATE DRILLED 3/27/13
4. WELL LOCATION:
NC Hiahwav 50
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
/113J69
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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
: Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
▪ 7. CASING: Depth Diameter Weight Material
: Top 0 Bottom 15.0 Ft. 2" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
: Top 0 Bottom 11.0 Ft. Portland Tremie
Top 11.0 Bottom 13.0 Ft. Bentonite Tremie
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top 15.0 Bottom 20.0 Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
CITY: ChinauaDin COUNTY DUDIin : Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope ❑Valley V(Flat ❑ Ridge ❑Other
LATITUDE 34 "DMS OR 34.80259924 DD
LONGITUDE 77 " DMS OR 77.78214097 DD
Latitude/longitude source: ❑GPS Vropographic 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.)
Marie & Billv's Grill
Facility Name
4463 NC Hiahwav 50
Facility ID# (if applicable)
Street Address
Chinauaoin NC 28521
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20.0'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO q�
c. WATER LEVEL Below Top of Casing: 4.0
(Use "+" if Above Top of Casing)
FT.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Bottom 20.0 Ft. #1 Sand
: Top 13.0
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
•
•
No samples taken
•
•
•
•
•
/
/
/
/
:• 12. REMARKS:
•
:fit O ESSi V UNIT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A
RE'' D HAS BE q PROVIDED TO THE WELL OWNER.
•
AC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• SIGNATURE 0 CERTIFIED WELL CONTRACTOR
•
at12b
DATE
Arnold Chapel.
PRINTED NAME OF PERSON CONSTRUCTING THE WELL,
II
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

04 10 2013 4:33pm - sthompson - H:\125 - ATC\__1253867_p1-03-21-13.dw9
TITLE FIGURE 1
SITE MAP
FORMER MARIE AND BILLY'S GRILL
4463 NORTH CAROLINA HIGHWAY 50
CHINQUAPIN, NORTH CAROLINA 28521
CAD FILE
1253867.DWG
TYPE CODE
PREP, BY
RK
TC
, A'SSOCIATES INC.
Raleigh, North Caiolina 27604 [phone] FAX [phone]
DATE
03- 21- 2013
PROJECT NO.
45.40675.5002