413067_Well Construction - GW1_20130422

NON RESIDENTIAL 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-6
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural ❑ Recovery ❑ Injection 0
Irrigation ❑ Other (list use) Air S Da ra e
DATE DRILLED 3/27/13
4. WELL LOCATION:
NC Hiahwav 50
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Chinauaoin COUNTY DUDIin
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope ❑Valley RfFlat ❑ Ridge ❑ Other
LATITUDE 34 "DMS OR 34.80259924 DD
LONGITUDE 77 " DMS OR 77.78214097 DD
Latitude/longitude source: ❑GPS VTopographic 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 ❑
c. WATER LEVEL Below Top of Casing: 4.0
(Use "+" if Above Top of Casing)
NO qf
FT.
1 3 0 7
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
7. CASING: Depth
Thickness/
Diameter Weight Material
Top 0 Bottom 15.0 Ft. 2" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
: Top 0 Bottom 11.0 Ft. Portland
Top 11.0 Bottom 13.0 Ft. Bentonite
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top 15.0 Bottom 20.0 Ft. 2
Bottom Ft.
Bottom Ft.
Top
Top
Method
Tremie
Tremie
Slot Size Material
in. .010 in. PVC
in. in.
in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
: Top 13.0 Bottom 20.0 Ft. #1 Sand
Top Bottom Ft.
Top Bottom Ft.
: 11. DRILLING LOG
: Top Bottom Formation Description
/ No samples taken
/
/
/
/
: 12. REMARKS:
•
HA 'ter' tiIi- J. n. t� . f ION
! - = 1°RMA n N. PR ,StMG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECQ D HAS BEEN P, OVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
4k2li3
DATE
Arnold Chapel
PRINTED NAME OF PERSON CONSTRUCTING THE WELL'.
At ' 7 2 i3 Form GW-1 b.
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Rev:+2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] ,:{

04/10/2013 4:33pm - sthompson - 1-:\125 - ATC\__1253867_01-03-21-13.ow9
O
113M 308dds 2,I1V
(d330)(III 3dA1) 113M ONI801INOW
(II 3dk1) 113M ONWO1INOW
3NIl ALd3d02ld
C—
rn
G7
•
N
`o.
aQ
go
\,
1 -0 m �
*7+
•,` Vj 1 y 1
• 1
CO
I
I4s-
N W %I
O ♦
� N /
�+. /O ( //
��9iti —♦
Tory O i/90
n
D
r
z
m
co
0
/\
N
NOTES:
1. MAP SCALE AND SITE FEATURES ARE APPROXIMATE.
T►n.EFIGURE 1
SITE MAP
FORMER MARIE AND BILLY'S GRILL
4463 NORTH CAROLINA HIGHWAY 50
CHINQUAPIN, NORTH CAROLINA 28521
V/TC
ASSOCIATES INC.
Raleigh, North Carolina 27604
[phone] FAX [phone]
CAD FILE
1253867.DWG
TYPE CODE
PREP. BY
RK
REV. BY
RK
SCALE
1"=40'
DATE
03-21-2013
PROJECT NO.
45.40675.5002