386003_Well Construction - GW1_20100730

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2911A
1. WELL CONTRACTOR:
Gary Skoalund
Well Contractor (Individual) Name
Mad Dawa. Inc.
Well Contractor Company Name
PO Box 398
Street Address
Iron Station NC 28080
City or Town State Zip Code
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(if applicable) B-19A
3. WELL USE (Check One Box) Monitonng it Municipal/Public ❑
Industrial/Commercial ❑ Agncultural 0 Recovery 0 Injection ❑
Imgation0 Other ❑ (list use) Pezometer
DATE DRILLED 7/21/10
4. WELL LOCATION:
Seaboard st
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
ciTY Charlotte COUNTY Meck
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley elat ❑ Ridge ❑ Other
LATITUDE 35 ° 14 893 0000 " DMS OR 3x xxXxXxxXX DD
LONGITUDE 80 ° 50 . 834 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source I,3PS Ofopographic map
(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
0 /2
CSX Railroad Tracks
Facility Name Facility ID# (if applicable)
Between Graham & N Church St
Street Address
Charlotte NC
City or Town State Zip Code
Maria Mu.feld
Contact Name
500 Water St
Mailing Address
Jacksonville FI A 32202
City or Town State Zip Code
( 9041 633-1517
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH. 49
b DOES WELL REPLACE EXISTING WELL? YES 0 NO qI
c. WATER LEVEL Below Top of Casing 6 FT
(Use "+" if Above Top of Casing)
2 / 40
40 / 49
/
12. REMARKS:
386003
d. TOP OF CASING IS 0 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) N/A METHOD OF TEST
f DISINFECTION: Type N/A Amount
g. WATER ZONES (depth)
Top 6 Bottom 49 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 39 Ft 1 sch40 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom 35 Ft Portland Trimmie
Top Bottom Ft
Top Bottom Ft
9. SCREEN. Depth Diameter Slot Size Material
Top 39 Bottom 49 Ft 1 in 010 in pvc
Top Bottom Ft in m
Top Bottom Ft in in
10. SAND/GRAVEL PACK:
Depth Size Matenal
Top 37 Bottom 49 Ft 2 pvc
Top Bottom Ft
Top Bottom Ft
Formation Descnption
gravel
sandy silt
weathered rock
RECER°77
JUL 3 0
inform, • It
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 =EEN PROVIDED EWE WNE
7/22/10
IGNATUCE D WELL CO 'TRA TOR DATE
Gary Skoalund
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