388701_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 TN 38464
City or Town State Zip Code
(931 ) 762-7548
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# NA
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(rf applicable) MW 15A
3 WELL USE (Check One Box) Monitoring L� Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10-8-2010
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 lelat ❑ Ridge ❑ Other
LATITUDE 35 ° 13 29 5000 DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 36 10 8000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source VGPS (]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 )
Ram I Bather
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
Mailing Address
Fort Myers
City or Town
( 2391 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 qI
c WATER LEVEL Below Top of Casing 21 FT
(Use "+" if Above Top of Casing)
3 4
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
Top 0 Bottom 3
Top Bottom
Top Bottom
Material
Ft Cement
Ft
Ft
Method
Pour
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
0 / 38
/
/
12 REMARKS
Formation Description
Overburden
a C, / a n
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information p [O , a" —
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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
R _ORD HAS BEAN PROv1GED TO TH6,WELL OWNER
S" NAT
/a.') 4.10
E 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