380907_Well Construction - GW1_20100202

i-7g440
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North C arolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1 WELL CONTRACTOR.
Tim Thomas
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9088 Northfield dr
FortMill sc 29707
City or Town State
( )_ [phone]
Zip Code
Area code- Phone number
2 WELL INFORMATION.
SITE WELL ID #(if applicable)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box) Monitoring i1 Municipal/Public ❑
Industnal/Commercial 0 Agricultural ❑ Recovery ❑ Injection 0
Imgation❑ Other 0 (list use)
DATE DRILLED 1/8/10
❑ PM Mt
Mecklenburg
TIME COMPLETED 3 30 AM
3. WELL LOCATION
CITY Charlotte COUNTY
8800 Crump rd Charlotte Mecklenburg, NC
(Street Name, Numbers Community Subdivision Lot No ,Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑Valley Xj Flat ❑Ridge 0 Other
(check appropriate box)
LATITUDE
May be in degrees,
minutes seconds or
in a decimal lonnat
LONGITUDE
Latitude/longitude source: ❑CPS ❑"topographic
(location of well must be shown on a USGS
attached to this form if not using GPS)
4 FACILITY- is the name of the business where the well is located
FACILITY ID #(If applicable)
map
topo map and
NAME OF FACILITY Caraustar
STREET ADDRESS 8800 Crump rd,
Charlotte NC
City or Town State Zip Code
CONTACT PERSON Tommy Fischer
MAILING ADDRESS 8000 Corporate Drive, Suite 200
Charlotte NC 28226
City or Town State
( 704 )- 541-8345
Zip Code
YES 0 NOE)
FT
Area code - Phone number
5 WELL DETAILS:
a. TOTAL DEPTH: 41'
b. DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing 39'
(Use "+" if Above Top of Casing)
$ 1 30td 9 0 7f't
c3
d TOP OF CASING IS -6" 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) METHOD OF TEST
f DISINFECTION. Type Amount
g. WATER ZONES (depth)
From To From To
From To From To
From To From To
6 CASING: Thickness/
Depth Diameter Weight Material
From 0' To 21' Ft PVC
From To Ft
From To 0' Ft
7 GROUT: Depth Material Method
From -6" TO19' Ft neat cement Trammed
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 21' To41' Ft 2" In 10 in PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK'
Depth Size Material
From 20' To 41' Ft trimmied#2--sand
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
0' 11' brown silty clays
11' 41' rock
41'
rc)i
n',ems
11 REMARKS: e ® 9 *2010
17- , A'
l0/or%','tn„L c,,i-, i ,, z,_ -,
iOcessfrtr 1i r()�
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECOR/D HAS BEEN PROVIDED TO THE WELL OWNER
SI
V„..i �%p�,.vr�j 1/08/10
r
SIC NA I URE OF CERTIFIED WELL CONTRACTOR DATE
Tim Thomas
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568
Form GW-lb
Rev 7/05