395412_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 State Zip Code
(910 ) 690-6688
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#MW-3R
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring VMunicipal/Public ❑
Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other ❑ (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 lelat ❑ Ridge ❑ Other
LATITUDE 35 0 059 '30 "DMS DD
LONGITUDE 80 0 0 31 ' 49 "DMS DD
Latitude/longitude source: 3PS DTopographic 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
Facility Name Facility ID# (if applicable)
see above
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 ❑ NOV
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 Method
Top .5 Bottom 6 Ft portland tremmie
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter 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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12. REMARKS:
JUN 24 2011
Information Prnraceit,-. t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED.WA'CCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVJDED TO THE WELL OWNER.
SIGN
Bryan Vest
6/8/11
CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
k h }
tibmit within 30 days of completion to Division of Water Qualit
�17 Mall Service Center Raleigh, NC 27699 161„Phone [phone]a
Form GW-lb
Rev. 2/09