386006_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
City or Town
f 704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-6
3. WELL USE (Check One Box) Monitonng it Municipal/Public 0
Industrial/Commercial ❑ Agncultural 0 Recovery ❑ Injection ❑
Imgation0 Other 0 (list use) Pezometer
DATE DRILLED 7/13/10
4. WELL LOCATION:
Seaboard st
NC 28080
State Zip Code
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY Charlotte COUNTY Meck
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley elat ID Ridge ❑Other
LATITUDE 35 " 14 • 1,635 0000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 " 50 • 3,439 0000 „ DMS OR 7x xxxxxxxXx DD
Latitude/longitude source (,BPS Qropographic 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 )
CSX RaiIrnad
Facility Name
Seaboard St
Street Address
Charlotte
Facility ID# (if applicable)
NC
City or Town
Maria Musfeld
State Zip Code
Contact Name
500 Water St
Mailing Address
Jacksonville FI A 39207
City or Town State Zip Code
( 904n 633-1517
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 21
b DOES WELL REPLACE EXISTING WELL? YES 0 NO qI
c WATER LEVEL Below Top of Casing 19 FT
(Use "+" if Above Top of Casing)
386006
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 19 Bottom 21 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 11 Ft 1 sch40 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom 7 Ft Portland Tnmmie
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
Top 11 Bottom 21 Ft 1 in 010 in pvc
Top Bottom Ft in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK:
Depth Size Material
Top 9 Bottom 21 Ft 2 pvc
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 /2
Formation Descnpbon
gravel
19 sandy silt
19 / 21 weathered rock
/
12. REMARKS:
JUL 3 i Lull
Information Processing Unit
DWQ/BOG
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 PROVIDEDS WELL • NER
7/22/10
SIG1�ATlT131dP CER I ��: WELL CO TRACTOR 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-1 b
Rev 2/09