387785_Well Construction - GW1_20101008

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3117-A
1 WELL CONTRACTOR
John Hardin
Well Contractor (Individual) Name
Hardin's Pump and Compressor
Well Contractor Company Name
3068 Old Thomasville Road
Street Address
Winston-Salem NC 27107
City or Town State Zip Code
(336 ) 769-9128
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(If applicable) MW-1
3 WELL USE (Check One Box) Monitoring [I Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ injection ❑
Irngation❑ Other ❑ (list use)
DATE DRILLED Auaust 13 2010
4 WELL LOCATION
1598 C C Camp Road
(Street Name Numbers Community, Subdivision Lot No , Parcel Zip Code)
CITY Elkin COUNTY Surr/
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley pfFlat ❑ Ridge ❑ Other
LATITUDE 36 ° 16 ' 49 0000 "DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 ° 47 20 0000 " DMS OR 8X XXXXXXxxx 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 )
Flkin Municipal Airport 0-000030
Facility Name Facility ID# Of applicable)
1598 C C Camp Road
Street Address
Flkin
City or Town
Town of Flkin
NC 28621
State Zip Code
Contact Name
226 N Bridae Street
Mailing Address
Flkin NC 28621
City or Town State Zip Code
( 3361 835-9800
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 50'
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO C/
c WATER LEVEL Below Top of Casing 25.81 FT
(Use "+" if Above Top of Casing)
Submit within 30 clays 'of completion to: Division otWater,Quality-" Information'Processing,,
1617 Mail Sennce.Center, Raleigh,`NC 27699-161, Phone [phone]
L
3 �j g � ,
a i U �J a;1 '8 it
d TOP OF CASING IS 0 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) N/A METHOD OF TEST N/A
f DISINFECTION Type N/A Amount
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 20 Ft 2" Sch 41 PVC
Top Bottom Ft
lop Bottom Ft
8 GROUT Depth Material Method
Top 1 Bottom 15 Ft Portland Pour
Top 15 Bottom 17 Ft Bentonite Pour
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top 20 Bottom 50 Ft 2 in 0 01 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 17 Bottom 50 Ft #3 Filter Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Description
0 / 29 Backfill
29 / 50 Orange/red. CLAY w/ silt. moist
/
12 REMARKS
CEIVED
CT-8mu
I HEREBY CE IFY THAT THIS WELL WAS CONST IN ACCORDANCE WITH
15A NCAC 2C wr L C• STRUCTION STAND RD A��Oft19rOeffesing Und
RECORD HAS EN :, ,VIPG^ TG TI'C WEL 0 ER D.WQ/sO
SIG
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
3
7A-
Form GW-lb
Rev 2/09