393381_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 (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#MW-1 A
State Zip Code
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other 0 (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 lelat ❑Ridge ❑Other
LATITUDE 34 0°58 '55 "DMS DD
LONGITUDE 80 ®° 27,31 "DMS DD
Latitude/longitude source: 3PS (]Topographic map
(location of well must be shown on a USGS topo map andattached to
this form•ifnot using GPS)
5. FACILITY (Name of the business where the well is located.)
Sandy's Cleaners
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
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 11
(Use "+" if Above Top of Casing)
YES r-1
NO rW
FT.
3 6 8i
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 NGAC 2G .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
Top -.25 Bottom 5 Ft. 2" Sch 40
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top .5 Bottom 1 Ft. portland
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Material
PVC
Method
tremmie
Diameter Slot Size Material
Top 5 Bottom 20 Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 3 Bottom 20
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /9
9 /18
18 /20
/
/
Size Material
Ft. Med. Quartz
Formation Description
Red silty clay
weathered rock
rock
/
/
/
/
12. REMARKS:
; .1 9 1 oil
u)torrnation Processin
VVnQ/Fir1g Whit
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 TKdRE OF CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmlt.within 30days of completion to Division o
17 Mail Service Center,;Raleigh„NC 27699'161, Phone
ater Quali
919) 807-630.
ormation Processing,
Form GW-lb
Rev. 2/09