388694_Well Construction - GW1_20101102

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3505
1 WELL CONTRACTOR
Joseph Fornecker
Well Contractor (Individual) Name
Miller Drlllina
Well Contractor Company Name
107 Helton Dr.
Street Address
Lawrenceburg TN 38464
City or Town
(931 ) 762-7548
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# NA
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(ifapplicable) MW 9B
3 WELL USE (Check One Box) Monitoring Ile Municipal/Public 0
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 10-14-2010
4 WELL LOCATION
15100 Albemarle Rd.
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY Charlotte COUNTY Meck.
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope 0Valley QrFlat ❑ Ridge ❑ Other
LATITUDE 35 0 13 . 554300 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 ° 36 , 9 2100 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source V3PS Dfopographic 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 )
Ram I eather
Facility Name Facility ID# Of applicable)
15100 Albemarle Rd
Street Address
Charlotte NC 28915
City or Town State Zip Code
Black & Veatch
Contact Name
4210 Metro Parkway Ste_220
Mailing Address
Fort Myers
City or Town
( 2396 278-3830
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 38
FL 33916
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO GI
c WATER LEVEL Below Top of Casing 21 FT
(Use "+" if Above Top of Casing)
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) <.5 METHOD OF TEST pump
f DISINFECTION Type NA Amount NA
g WATER ZONES (depth)
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 38 Ft 2 sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 3
Top 3 Bottom 34
Top 34 Bottom 37
Material
Ft Cement
Ft Bent Grout
Ft Bentonite
Method
Pour
Tremie-Pump
Pour -Tag
9 SCREEN Depth Diameter Slot Size Material
Top 38 Bottom 48 Ft 2 in 10 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 36 Bottom 48 Ft #1 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Description
0 / 48 Overburden
/
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NUV 4,0 4. Lu iv
/ 1 1...4
/ Information 1-10-0a"..a
12 REMARKS
UVV W'-"—
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RD HAS BEEN PROVIDED TO THE WELL OWNER
In- i5-lc
NATURE OF CERTIFIED WELL CONTRACTOR DATE
Joseph Fornecker
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev 2/09