384785_Well Construction - GW1_20100623

3
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
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(rfapplicable) N/A
SITE WELL ID #(rfapplicable) MW-31
3. WELL USE (Check One Box) Monitonng Ct{ Municipal/Public 0
Industrial/Commercial 0 Agncultural 0 Recovery ❑ Injection 0
Imgation❑ Other ❑ (list use)
DATE DRILLED 6/9/2010
4. WELL LOCATION:
BAILEY RD &STARCREEK DR.
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY CORNELIUS COUNTY MECKLEN611
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley Fiat ❑ Ridge ❑ Other
LATITUDE 35 0 27 • 710 0000 ^ DMS OR 3x.xxxxxxxxx DD
LONGITUDE 80 0 51 • 2450000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source IMPS ['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 )
Facie e Facility ID# (if applicable)
BAIT FY RD &STARCRFFK DR
Street Address
CORNFLIUS NC 28031
City or Town State Zip Code
BRIAN BFI I IS
Contact Name
1410 COMMONWFAI TH DR UNIT 101
Mailing Address
WII MINGTON
City or Town
NC 28403
State Zip Code
( 910n 256-9277
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH 40
b DOES WELL REPLACE EXISTING WELL? YES 0 NO q/
c WATER LEVEL Below Top of Casing N/A FT
(Use "+" if Above Top of Casing)
3 785
d TOP OF CASING IS 3 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)
f DISINFECTION:
METHOD OF TEST
Ype Wig
Amount
g. WATER ZONES (depth)
Top 3 S Bottom `4 0 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight
Top 0 Bottom 30 ELK._ " SCH4(
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal
Top 0 Bottom 26 Ft PORTLAND
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth Diameter
Top 30 Bottom 40 Ft p" in
Top Bottom Ft in
Top Bottom Ft in
10 SAND/GRAVEL PACK
Depth Size
Top 28 Bottom 40 Ft
Top Bottom Ft
Top Bottom Ft
Material
PVC
Method
TRIMIE
Slot Size
010 in
in
m
Material
PVC
Material
SAND
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 1' TOPSOIL
1' / 20' FILL
20' / 40 RED SANDY SILT
/
12 REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CO
15A NCAC 2C, WELL CONSTRUCT! • STANDAR
RECORD HAS VIDEO T'1 WEL
SIGNATUR
N
RUCTED IN ACCORDANCE WITH
AND THA ✓I PY OF THIS
NER
6/11/201
CER F • i WELL CONT CTOR DATE
Gary Skoglund
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]
RE"CEI V�GW 1b
Information Process'nu, Rev 2/09
JUN 2 3 201U
Information Processing Unit
DWQ/BOG