388699_Well Construction - GW1_20101102

NONRESIDENTIAL 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
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)
TN 38464 Top NA Bottom NA Top NA Bottom NA
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(ifapplicable) MW 13
3 WELL USE (Check One Box) Monitoring El Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10-11-2010
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
4. WELL LOCATION 9. SCREEN Depth Diameter Slot Size Material
15100 Albemarle Rd. Top 8 Bottom 23 Ft 2 in 20 in PVC
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code) Top 23 Bottom 38 Ft 2 in 10 in PVC
CITY Charlotte COUNTY Meck. Top Bottom Ft in in
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley prFlat ❑Ridge ❑Other 10 SAND/GRAVEL PACK
LATITUDE 35 . 13 • 25 3000 " DMS OR 3x XXXXXXXXX DD DepthSize Material
Top 3 Bottom 6 Ft #1 Sand
LONGITUDE 80 . 36 • 10 3000 " DMS OR 7x xxxxxxxxx DD Top 6 Bottom 23 Ft #2 Sand
Latitude/longitude source VGPS propographic map Top 23 Bottom 38 Ft #1 Sand
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 11 DRILLING LOG
5 FACILITY (Name of the business where the well is located) Top Bottom Formation Descnption
Ram I eather 0 / 38 Overburden
Facility Name Facility ID# (if applicable) /
15100 Albemarle Rd /
Street Address /
Charlotte NC 28215 /
City or Town State Zip Code /
Black & Veatch /
Contact Name /
4210 Metro Parkway Ste 220 /' @ tf -- r%
Mailing Address /
Fort Myers FI 33916 / ► rixi A 61 ')n4n
City or Town State Zip Code
t ha LUIU
12 REMARKS
( 239n 278-3830
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 38
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO C�
c WATER LEVEL Below Top of Casing 21 FT
(Use "+" if Above Top of Casing)
Informatinn Q :.•.. < i i a
DWQ/BQG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BE=N PRO\OOED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Joseph Fornecker
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
!A
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