394859_Well Construction - GW1_20110610

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North C'.arolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2675
1. WELL CONTRACTOR:
Robert Miller
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9088 Northfield Dr.
Ft. Mill S.C.
City or Town State
( )- [phone]
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-12
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring M Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 5-18-11
❑ PM
Union
TIME COMPLETED. 12 :30 AM
3. WELL LOCATION:
CITY: Marshville COUNTY
8613 US Highway 74 East
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑Valley ICI Flat 0 Ridge 0 Other
(checic appropriate box)
LATITUDE
May be in degrees,
minutes. seconds or
in a decimal format
LONGITUDE
Latitude/longitude source: ❑GPS ❑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 Watkins Grocery
STREET ADDRESS 8613 US Highway 74 East
Marshville S.C.
City or Town State Zip Code
CONTACT PERSON Pyramid Environmental
MAILING ADDRESS P.O. Box 16265
Greensboro N.C. 27416-0265
City or Town State
( 336 )- 335-3174
Zip Code
YES 0 NOR7
FT. •
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 20'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
354859
d. TOP OF CASING IS 0 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):
From To From To
From To From To
From To From To.
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 5' Ft. 2" sch40 pvc
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To 2' Ft. port land pour
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 5' To 20 ' Ft.2" in. An in. pvc
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From 3' To 20 ' Ft. 20/30 silica sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To. Formation Description
0 5' pwr -
5' 20' Rock
Prir-
.,t7iv/
20' �uw
I 0 2a1
lrl€ormdt(t�c:nqYY��a;roc
sirt9
UU
11. REMARKS:
One foot bentonite seal from 2' to 3'
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 PROVIDED. TO THE WELL OWNER. 5-18-11
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Robert Miller
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submitthe 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
Unit