388698_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 Drilling
Well Contractor Company Name
107 Helton Dr
Street Address
Lawrenceburg
City or Town
(931 ) 762-7548
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# NA
TN 38464
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(if applicable) MW 12
3 WELL USE (Check One Box) Monitoring V Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 10-11-2010
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 ❑Valley 'Flat ❑ Ridge ❑ Other
LATITUDE 35
° 13 ' 30 2000
" DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 36 ' 9 8000 " DMS OR 7X xxxxxxxxx DD
Latitude/longitude source {, OPS Ofopographic 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# (if applicable)
15100 Albemarle Rd
Street Address
Charlotte NC 28215
City or Town
Black & Veatch
Contact Name
4210 Metro Parkway Ste 220
Mailing Address
Fort Myers
City or Town
( 239. 278-3830
Area code Phone number
6 WELL DETAILS'
a TOTAL DEPTH 38
State Zip Code
FL 33916
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c WATER LEVEL Below Top of Casing 21
(Use "+" if Above Top of Casing)
FT
f_ toy
eJi J
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 8 Ft 2 sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 3 Ft Cement Pour
Top Bottom Ft
Top Bottom Ft
9. SCREEN Depth Diameter Slot Size Material
Top 8 Bottom 23 Ft 2 in 20 in PVC
Top 23 Bottom 38 Ft 2 in 10 in PVC
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 3 Bottom 6 Ft #1 Sand
Top 6 Bottom 23 Ft #2 Sand
Top 23 Bottom 38 Ft #1 Sand
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 38 Overburden
/
12. REMARKS
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information Processing Unit
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECDRD HAS BEEJJ PROVIDED TO THE WELL OWNER
(0- I S-IQ
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-lb
Rev 2/09