389611_Well Construction - GW1_20101221

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3505
1 WELL CONTRACTOR
Joe Fornecker
Well Contractor (Individual) Name
McCall Brothers
Well Contractor Company Name
6700 Brookshire Blvd
Street Address
Charlotte NC 28216
City or Town
( 704) 399-1506
Area code Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT# 10004772
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(if applicable) NA
3 WELL USE (Check Applicable Box) Residential Water Supply [�
DATE DRILLED 1 1-18-2010
TIME COMPLETED 3:00 AM ❑ PM Eli
4 WELL LOCATION
CITY Charlotte COUNTY Meck
Fallina Meadows Lane
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑Valley CdFlat
LATITUDE 35
4
LONGITUDE 80 ° 58
❑ Ridge ❑ Other
56 0000
" DMS OR 3x XXXXXXXXX DD
48 7000
Latitude/longitude source VGPS
(location of well must be shown on
this form if not using GPS)
5 WELL OWNER
Scott Dayton
" DMS OR 7x XXXXXXXXX DD
['Topographic map
a USGS topo map andattached to
Owner Name
16120 Fallina Meadows Lane
Street Address
Charlotte NC 28273
City or Town State Zip Code
(704 ) 962-5727
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH. 620
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO CAI
c WATER LEVEL Below Top of Casing 15 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 5 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) 25 METHOD OF TEST Air Lift
f DISINFECTION. Type HTH Amount 26 OZS
Top NA
g WATER ZONES (depth)
Top 140 Bottom 145
Top 610 Bottom 615
Top NA Bottom NA
7 CASING
Top 1 5
Top NA
Top NA
8 GROUT
Top 0
Top NA
Top NA
t.'
Top 2 gpm Bottom NA
Top 23 gpm Bottom NA
Top NA Bottom NA
Thickness/
ky
Depth Diameter Weight Material
Bottom -26 5 Ft 6 125 sch40 PVC
Bottom NA Ft NA NA NA
Bottom NA Ft NA NA NA
Depth Material
Bottom 20 Ft Bentonite
Bottom NA
Ft NA
Bottom NA Ft NA
Method
Pour w water
NA
NA
9 SCREEN Depth Diameter Slot Size Material
Top NA Bottom NA Ft NA in NA in NA
Top NA Bottom NA Ft NA in NA in NA
Top NA Bottom NA Ft NA in NA in NA
10 SAND/GRAVEL PACK
Depth
Bottom NA
Size Material
Ft NA NA
Top NA Bottom NA Ft NA NA
Top NA Bottom NA Ft NA NA
11 DRILLING LOG
Top Bottom
0 /16
16 /620
12 REMARKS
Formation Descnption
Overburden
Black rock with small white bands
DEC2010
Vdf.TE ± C,QU1vL t •'aC-' 1 tai�v
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 BEEN
P- e1 D TO THE.WELL OWNER
RTIFIED WELL CONTRACTOR DATE
Joe Fornecker
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30:days of completion to:.Division-of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone :[phone]
Information Processing,
Form GW-la
Rev 2/09