390601_Well Construction - GW1_20110110

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
(910 ) 690-6688
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#VE-1
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
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 DRILLED12/8/10
4. WELL LOCATION:
8613 Hwy 74
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Marshville COUNTYUnion
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley Vlat ❑Ridge ❑Other
LATITUDE 34 0 °59 '17 "DMS DD
LONGITUDE S0 0 ° 18 ' 59 " DMS DD
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.)
Watkin's Grocery
Facility Name
see above
Facility ID# (if applicable)
Street Address
see above
NC
City or Town
Kristin Beckwith
State Zip Code
Contact Name
PO Box 16265
Mailing Address
Greensboro
City or Town
( 336 ) 335-3174
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 55
NC 27416
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO V
c. WATER LEVEL Below Top of Casing: 31
(Use "+" if Above Top of Casing)
FT.
3 "0
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 Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top -.25 Bottom 50 Ft. 2" Sch 40 PVC
Top 0 Bottom 30 Ft. 5" Sch 40 PVC
Top Bottom Ft.
8. GROUT: Depth Material
Top .5 Bottom 45 Ft portland
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 50
Top
Top
Method
tremmie
Diameter Slot Size Material
Bottom 55 Ft.2 in. .010 in. PVC
Bottom Ft. in. in.
Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 48 Bottom 55 Ft. Med. Quartz
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 7 brown silty sand
7 / 55 rock
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12. REMARKS:
JAN 0 2011
In1Grrri:-.,on Processing 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.
-471f41-3 1/5/10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
, Submit within 30 days of completion, to: Division of
1617 Mail Service Center, Raleigh, NC 27696-161, Phone
Dater Quall
919) 807-63(
rocessin
Form GW-1 b
Rev. 2/09