386950_Well Construction - GW1_20100908

NONRESIDENTIAL WELL CONSTRUCTION RECORD e➢
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 Dnlling, 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 FERMIUM W-1
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID Of applicable)
3 WELL USE (Check One Box) Monitonng'Muniapal/Public ❑
Industnal/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED7/12/10
4. WELL LOCATION-
16324 York Rd.
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
cln Charlotte CouNTYMeCk.
TOPOGRAPHIC / LAND SETTING (check appropnate box)
El Slope ❑Valley 141at ❑Ridge ❑Other
LATITUDE 36 °17 ,32 " DMS DD
LONGITUDE 80 ° 01 .09 " DMS DD
Latitude/longitude source OPS Dropographic 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 )
Docksiders Marina
Facility Name
see above
Facilty ID# (rf applicable)
Street Address
see above
NC
City or Town
Laura Minor
State Zip Code
Contact Name
410 E Franklin Street
Mailing Address
Monroe NC 28112
City or Town State Zip Code
( 704) 289-5881
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 20
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO iV
c WATER LEVEL Below Top of Casing 12
(Use "+" if Above Top of Casing)
FT
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 Matenal
Top - 25 Bottom 5 Ft 2" Soh 40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 5 Bottom 1 Ft portland tremmle
Top Bottom Ft
Top Bottom Ft
9. SCREEN Depth Diameter Slot Size Material
Top 5 Bottom 20 Ft 2 in 010 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK.
Depth Size Material
Top 3 Bottom 20 Ft Med Quartz
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /7
7 /20
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12 REMARKS.
Formation Descnption
Sand
weathered rock
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RED HAS BEEN PROVIDED TO THE WELL OWNER
SIG ` UREOF CERTIFIED WELL CONTRACTOR DATE
Ban Vest
PRRIN PRINTED NAME OF PERSON CONRIEIGI 1NEE . D
7/27/10
SEP 0 8 2'FdPrnGW-1b
Information Processing Unit
DWQ/BOG