382541_Well Construction - GW1_20100101

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma 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
NC 28786
State Zip Code
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(rf applicable)
SITE WELL ID #(f applicable) MW-1
3 WELL USE (Check One Box) Monitonng V Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
IrngationD Other ❑ (list use)
DATE DRILLED 4/9/10
4 WELL LOCATION
204 East State Street. 28711
(Street Name, Numbers Community, Subdivision, Lot No Parcel Zip Code)
cITY Black Mountain
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley vfFlat ❑Ridge
LATITUDE 35 '
LONGITUDE 82
COUNTY Buncombe
(check appropnate box)
❑ Other
" DMS OR 35 619383 DD
" DMS OR 82 318211 DD
Latitude/longitude source (PS propographic 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
Facility ID# (if applicable)
NC 28711
State Zip Code
Contact Name
903 West Kula Street
Mailing Address
Fast Flat Rock
City or Town
NC 28762
State Zip Code
( 828b 697-0501
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 24.0
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO p1
c WATER LEVEL Below Top of Casing 1 1 .0 FT
(Use "+" if Above Top of Casing)
g, L
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) METHOD OF TEST
f DISINFECTION Type Amount
g WATER ZONES (depth)
Top 11 0 Bottom 24 0 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 0 Bottom 9 0 Ft 2 Sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 0 Bottom 6 0 Ft Portland Tremmie
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top 9 0 Bottom 24 0 Ft 2 in 10 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 7 0 Bottom 24 0 Ft 2 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
0 0 / 5 0 Dark Bm Silty Sand
5.0 / 10.0 Tan Silty Sand
10 0 / 24 0 Grey Silty Sand
/
/
12 REMARKS
Pi i 1 6 min
Information Processing Unit
vvvt„
S WELL : i SNSTRUCTED IN ACCORDANCE WITH
DS AND THAT A COPY OF THIS
OWNER
4/14/10
SIGNATUL CONTRACTOR DATE
Everard Baker Jordan
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Information Processing,
TMS
MAD a e 9 _ _ _
Form GW-lb
Rev 2/09