413063_Well Construction - GW1_20130422

1. WELL CONTRACTOR:
Arnold Chapel
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2487
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-10
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
IrrigationD Other i(Iist use) Air Sparge
DATE DRILLED 3/28/13
4. WELL LOCATION:
NC Hiahwav 50
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ChinauaDin COUNTYDUDIIn
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley "Flat ❑ Ridge DOther
LATITUDE 34 "DMS OR 34.80259924 DD
LONGITUDE 77 " DMS OR 77.78214097 DD
Latitude/longitude source: DGPS Vifopographic 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
Chinauaain 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 ❑ NO ql
c. WATER LEVEL Below Top of Casing: 4.0
(Use "+" if Above Top of Casing)
FT.
413063
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.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
: Top 13.0 Bottom 20.0 Ft. #1
Top Bottom Ft.
Top Bottom Ft.
Size
Material
Sand
: 11. DRILLING LOG
: Top Bottom Formation Description
•
•
/ No samples taken
/
/
/
1• 2. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECORD S BEE f,,'OVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Arnold Chapel j..a
PRINTED NAME OF PERSON CQNSTRU,CTING THE:WELL
Submit within 30 days of completion to: Division of Water Quality
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
nrvn
i 6 _L) d Form GW-1 b
Information Processing, 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
!ATC
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