393376_Well Construction - GW1_20110419

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 jIndividual) 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-2A
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(If applicable)
3. WELL USE (Check One Box) Monitoring Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED2/23/11
4. WELL LOCATION:
3813 Hwy 74
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wingate COUNTYUnion
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley What ❑Ridge El Other
LATITUDE 34 0°58 .55 "DMS
LONGITUDE 80 ®° 27,31 "DMS
Latitude/longitude source: R PS EITopograph.ic map
(location of well must be shown on a USGS topo map andattached to
this fomrif not"using GPS)
5. FACILITY (Name of the business where the well is located.)
Sandy's Cleaners
DD
DD
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 NC 27416
City or Town State Zip Code
(336 ) 335-3174
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20
h, DOES WELL REPLACE EXISTING WELL? YES ❑ NO I9/
c. WATER LEVEL Below Top of Casing: 11
(Use "+" if Above Top of Casing)
FT.
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
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top -.25 Bottom 5 Ft. 2"
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top .5 Bottom 1 Ft. portland
Top Bottom Ft.
Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
Weight
Sch 40
Material
PVC
Method
tremmie
9. SCREEN: Depth Diameter Slot Size Material
Top 5 Bottom 20 Ft. 2 in. .010 in. PVC
Top Bottom
Top Bottom
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 3 Bottom 20 Ft. Med. Quartz
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 9 Red silty clay
9 / 18 weathered rock
18 / 20 rock
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12. REMARKS:
Ri 11 1 9 2011
irlforrhation
DWodg ' vnrt
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.
3/4/11
SIGNA )E OF CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit withiri 30 days of completion to Division of
17 Mail Service Center, Raleigh, NC 27699'161, Phone
titer Quality - information Processln
119) 807-6300,
Form GW-lb
Rev. 2/09