382540_Well Construction - GW1_20100101

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3172
1 WELL CONTRACTOR
Everard Baker Jordan
Well Contractor (Individual) Name
Jordan Environmental, LLC
Well Contractor Company Name
68 Little Horse Road
Street Address
Waynesville
City or Town
(828 ) 734-2612
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-2
3 WELL USE (Check One Box) Monitonng V Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 4/9/10
4 WELL LOCATION
204 East State Street. 28711
NC 28786
State Zip Code
(Street Name, Numbers, Community, Subdivision Lot No , Parcel, Zip Code)
CITY Black Mountain COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑ Valley 'Flat ❑ Ridge ❑ Other
LATITUDE 35 ° " DMS OR 35 619383 DD
LONGITUDE 82 " DMS OR 82 318211 DD
Latitude/longitude source 3PS ['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 )
Robo Chevron Station 0-004164
Facility Name
204 Fast State Street
Street Address
Black Mountain
City or Town
Chin Gould
Contact Name
203 West Kina Street
Facility ID# (if applicable)
NC 28711
State Zip Code
Mailing Address
Fast Flat Rock
City or Town
( 828,6 697-0501
Area code Phone number
NC 28762
State Zip Code
6 WELL DETAILS
a TOTAL DEPTH 24.Q
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO c/
c WATER LEVEL Below Top of Casing 11.0 FT
(Use "+" if Above Top of Casing)
3''
d TOP OF CASING IS 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)
f DISINFECTION Type Amount
g WATER ZONES (depth)
Top 11 0 Bottom 24 0 Top
Top Bottom Top
Top Bottom Top
METHOD OF TEST
7 CASING Depth Diameter
Top 0 0 Bottom 9 0 Ft 2
Top Bottom Ft
Top Bottom Ft
Bottom
Bottom
Bottom
Thickness/
Weight
Material
Sch40 PVC
8 GROUT Depth Material
Top 0 0 Bottom 6 0 Ft Portland
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth Diameter
Top 9 0 Bottom 24 0 Ft 2 in
Top Bottom Ft in
Top Bottom Ft in
10 SAND/GRAVEL PACK
Depth
Top 7 0 Bottom 24 0
Top
Top
Method
Tremmie
Slot Size Material
10 in PVC
in
in
Size Material
Ft 2 Sand
Bottom Ft
Bottom Ft
11 DRILLING LOG
Top Bottom
00 /50
5.0 / 24.0
/
/
12 REMARKS
Formation Description
Dark Bm Silty Sand
Tan Silty Sand
HrK Y 6 2(110
1nrorrriatron Proc.ccrn 1 ram. s
UWQ/BOG
I DO HEREBY CERTIFY THAT T
15A NCAC 2C WELL CONST,RUCT.
S BEEN
SIGNATURE OF CERTIFIED
IN ACCORDANCE WITH
AT A COPY OF THIS
4/14/10
LL CONTRACTOR DATE
Everard Baker Jordan
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to• Division of Water Quality - Information Processing, TMS
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
JAN 1 8 2013
Form GW-1 b
Rev 2/09