385517_Well Construction - GW1_20100715

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3544 3 5 5
1 WELL CONTRACTOR
Joshua Ellingworth
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 Of applicable) MW-A
3 WELL USE (Check One Box) Monitoring Li{ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 4/27/10
4 WELL LOCATION
10023 North Trvon Street
(Street Name Numbers Community Subdivision, Lot No Parcel Zip Code)
CITY Charlotte COUNTY Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley IifFlat ❑Ridge ❑Other
LATITUDE 35 ° 19 332 0000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 0 44 40 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source OGPS ittopographic 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 )
Fxxon Mobil
Facility Name Facility ID# (if applicable)
10023 North Trvon Street
Street Address
Charlotte NC 28262
City or Town State Zip Code
Contact Name
Mailing Address
City or Town
�)
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 15.0'
b DOES WELL REPLACE EXISTING WELL?
State Zip Code
YES ❑
c WATER LEVEL Below Top of Casing 13.0
(Use "+' if Above Top of Casing)
NO51
FT
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 5 0 Ft 2" Sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 1 5 Ft Portland
Method
Tremle
Top 1 5 Bottom 3 0 Ft Bentonite Tremie
Top Bottom Ft
9 SCREEN Depth Diameter
Slot Size Material
Top 5 0 Bottom 15 0 Ft 2 in 010 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth
Top 3 0 Bottom 15 0
Top
Top
Bottom
Bottom
Size
Ft #1
Ft
Ft
Material
Sand
11 DRILLING LOG
Top Bottom Formation Description
8 0 / 12 0' Tan/white, moist, medium/coarse
/ SAND & SILT
12 REMARKS
1[11 1 5 7111Q
Intnrmatirsn Pr,t9 ^SSina Unit
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C W CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HA = PROWED TO . WELL OWNER
Cf/
7/ )
SIG TURF OF CERTIFIED LL CONTRACTOR DATE
Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit-itiittiin 3Uydays of completlon`twiDtvision of Water Quality - Information` Processing,
' 1617 Mad°Seance Center, Raleigh; -NC 27699-161; Phone [phone] - _
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Form GW-1 b
Rev 2/09

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