HomeMy WebLinkAbout390620_Well Construction - GW1_20110110NUN RESIDENTIAL 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
City or Town
9(10 ) 690-6688
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#MW-4
NC 28327
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED12/6/10
4. WELL LOCATION:
3615 Hwy 74 East
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wingate
COUNTYUniM
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley lelat ❑ Ridge ❑ Other
LATITUDE 36 0 °17 .32 "DMS
LONGITUDE 80 0 ° 01 ' 09
DD
"DMS DD
Latitude/longitude source: 3PS Oropographic 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.)
Wingate Valero
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
City or Town
( 704 ) 289-5881
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 35
NC 28112
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO (i9/
c. WATER LEVEL Below Top of Casing: 20 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS -•25 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
7. CASING: Depth
Top -.25 Bottom 10
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft. 2" Sch 40 PVC
Ft.
Ft.
8. GROUT: Depth Method
Top .5 Bottom 6 tremmie
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 10 Bottom 35
Top Bottom
Top Bottom
Material
Ft. portend
Diameter Slot Size Material
Ft.2 in. .010 in. PVC
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 8 Bottom 35 Ft. Med.
Top Bottom Ft.
Top Bottom Ft.
Material
Quartz
11. DRILLING LOG
Top Bottom Formation Description
0 / 12 brown silty clay
12 /35 rock
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12. REMARKS:
t: L
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 BEENPROVID TO THE WELL OWNER.
1/5/10
CERTIFIED WELL CONTRACTOR DATE
ATUR �OF
SIGV
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmif.within;30rdays of completion to ''Division of
1TMail Service Center, Raleigh, NC,27699 `161, Phone
ater Quali
919) 807-6
rocessin
Form GW-lb
Rev. 2/09