413065_Well Construction - GW1_20130422

413065
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): NIA METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
: g. WATER ZONES (depth):
Hillsborough NC 27278 : Top N/A Bottom Top Bottom
City or Town State Zip Code : Top Bottom Top Bottom
(919 ) 644-2814 : Top Bottom Top Bottom
Area code Phone number . Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# i Top 0 Bottom 15.0 Ft. 2" Sch40 PVC
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID #(if applicable) AS-8 : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑ : 8. GROUT: Depth Material Method
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection ❑ : Top 0 Bottom 11.0 Ft. Portland Tremie
Irrigation0 Other 1l(list use) Air SDarae : Top 11.0 Bottom 13.0 Ft. Bentonite Tremie
DATE DRILLED 3/28/13 ; Top Bottom Ft.
4. WELL LOCATION: : 9. SCREEN: Depth Diameter Slot Size Material
NC Highway 50 : Top 15.0 Bottom 20.0 Ft. 2 in. .010 in. PVC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) Top Bottom Ft. in. in.
CITY: ChinauaDin COUNTY DuDlin : Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley6eFlat ❑ Ridge DOther : 10. SAND/GRAVEL PACK:
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
Depth Size Material
LATITUDE 34 " DMS OR 34.80259924 DD
Top 13.0 Bottom 20.0 Ft. #1 Sand
LONGITUDE 77 ° " DMS OR 77.78214097 DD
TopBottom Ft.
Latitude/longitude source: ❑GPS • (Topographic map : Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) : 11. DRILLING LOG
5. FACILITY (Name of the business where the well is located.) : Top Bottom Formation Description
Marie & Billv's Grill / No samples taken
Facility Name Facility ID# (if applicable) : /
4463 NC Hiahwav 5Q /
Street Address : /
Chinauanin NC 28521
City or Town State Zip Code :
•
Contact Name • ; } �L L �,tF j,,`,
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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 ❑ NO !-
c. WATER LEVEL Below Top of Casing: 4.0
(Use "+" if Above Top of Casing)
FT.
•
•
12. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REC•'.;r HAS BEET ROVIDED TO THE WELL OWNER.
47413
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
• Arnold Chapel r .
PRINTED NAME OF PERSON ,CONSTR,UCTING,THEWELL:',
41 •
Submit within 30 days of completion to: Division of Water Quality - Information Procesing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
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Form: GW-1 b
Re.2/09

04/10/2013 4:33pm - sthompson - H:\125 - ATC\_-1253B67_p1-03-21-13.N 9
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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
"‘1",/AliC
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