395410_Well Construction - GW1_20110624

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3580
1. WELL CONTRACTOR:
Bryan Vest
Well Contractor (Individual) Name
Ransier Environmental Drilling, Inc.
Well Contractor Company Name
1 Piney Point
Street Address
Whispering Pines
NC 28327
City or Town
9(10 ) 690-6688
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#MW-6R
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable)
3. WELL USE (Check One Box) Monitoring fieMunicipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED5/23/11
4. WELL LOCATION:
13801 Providence Road
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Weddington COUNTYUnion
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley (Ole ❑Ridge ❑Other
LATITUDE 35 ® °59 ,30 " DMS
LONGITUDE 80 ®° 31.49 " DMS
Latitude/longitude source: 3PS ['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.)
Brewer-Hendly Oil Company
DD
DD
Facility Name
see above
Facility ID# (if applicable)
Street Address
see above
NC
City or Town
Laura Minor
State Zip Code
Contact Name
410 E. Franklin Street
Mailing Address
Monroe NC 28112
City or Town State Zip Code
(704 ) 289-5881
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 12
(Use "+" if Above Top of Casing)
FT.
d. TOP OF CASING IS 2.5 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):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top -.25 Bottom 10 Ft. 2" Sch 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top .5 Bottom 6 Ft. portland
Top
Top
Bottom
Bottom
Ft.
Ft.
9. SCREEN: Depth Diameter
Method
tremmie
Slot Size Material
Top 10 Bottom 20 Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 8 Bottom 20 Ft. Med. Quartz
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 20 brown/gray silty sand
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/
/
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12. REMARKS:
JUN 24 zo»
Inforrnath,., n
' 0zessin
g Unit
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.
r'SIGN UR— F CERTIFIED WELL CONTRACTOR
Bryan Vest
6/8/11
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
DATE
ubmit' within 3.
completion to
17 MailNService Center, Raleigh,• NC, 27699-1
Ivlslon of Water Quali
hone t (919),807-631
Form GW-lb
Rev. 2/09