413066_Well Construction - GW1_20130422

NONRESIDENTIAL 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-7
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
IrrigationD Other Ci(list use) Air SDarae
DATE DRILLED 3/28/13
4. WELL LOCATION:
NC Hiahwav 50
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ChinauaDin COUNTY DuDlln
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope [Walley geFlat ❑ Ridge ❑ Other
LATITUDE 34 "DMS OR 34.80259924 DD
LONGITUDE 77 " DMS OR 77.78214097 DD
Latitude/longitude source: ❑GPS 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.)
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 Gi
c. WATER LEVEL Below Top of Casing: 4.0
(Use "+" if Above Top of Casing)
FT.
413066
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
: Top 0 Bottom 11.0
Material
Ft. Portland
Method
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.
Top Bottom Ft. 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:
p
11 1
INFORMATION PROCP,F.31410 UN'-,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOHAS BEET PROVIDED TO THE WELL OWNER. •
SIGNATURE OF
46115
ERTIFIED WELL CONTRACTOR DATE
Arnold Chapel
PRINTED NAME OF PERSON CONSTRUCTING THE WE__,
Submit within 30 days of completion to: Division of Water Quality Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
1
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Rev. 2/09

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NOTES:
1. MAP SCALE AND SITE FEATURES ARE APPROXIMATE.
TITLE FIGURE 1
SITE MAP
FORMER MARIE AND BILLY'S GRILL
4463 NORTH CAROLINA HIGHWAY 50
CHINQUAPIN, NORTH CAROLINA 28521
/ft'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