389485_Well Construction - GW1_20101119

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #3580
1 WELL CONTRACTOR
Bryan Vest
Well Contractor (Individual) Name
Ransier Environmental Drilling, Inc
Well Contractor Company Name
1 Piney Point
Street Address
Whispering Pines NC 28327
City or Town State Zip Code
(910 ) 690-6688
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#MW-1
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED10/28/10
4 WELL LOCATION
6007 Tuckaseegee Rd
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY Charlotte COUNTYMeCk
TOPOGRAPHIC / LAND SETTING (check appropriate box)
['Slope ❑ Valley V Iat ❑ Ridge ['Other
LATITUDE 35 ® .14 .38 "DMS DD
LONGITUDE 80 ®° 55 ' 29 "DMS DD
Latitude/longitude source 3PS °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 )
Anthony Property
Facility Name
see above
Facility ID# (if applicable)
Street Address
see above
NC
City or Town
Robert Payne
State Zip Code
Contact Name
807 Bullard Lane
Mailing Address
Graham
City or Town
( 336 ) 376-0394
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 50
NC 27253
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO t11I
c WATER LEVEL Below Top of Casing 35 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS - 25 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) METHOD OF TEST
f DISINFECTION Type Amount
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top - 25 Bottom 25 Ft 2" Sch 40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 5 Bottom 21 Ft portland tremmie
Top Bottom Ft
Top Bottom Ft
, 9 SCREEN Depth Diameter Slot Size Material
Top 25 Bottom 50 Ft 2 in 010 in PVC
Top Bottom Ft in in
, Top Bottom Ft in in
: 10 SAND/GRAVEL PACK
Depth Size Material
Top 23 Bottom 50 Ft Med Quartz
Top Bottom Ft
• Top Bottom Ft
: 11 DRILLING LOG
Top Bottom Formation Description
0 / 15 backflll
15 /30 red silt
30 / 50 brown silt
/
/ NU V r "
2UM
/ atran i-re _
/ vwO/Rr,'si/tg Uw.
12 REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO D HAS BEEN PJO%IDEDTO THE WELL OWNER
,( 11/3/10
SIGN9.T[JR F CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
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