393378_Well Construction - GW1_20110419

NONRESIDENTIAL WELL CONSTRUCTION RECORD
3 ;3
North Carolina Department of Environment and Natural Resources- Division of Water Quality U'
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-5
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
Irrigation0 Other 0 (list use)
DATE DRILLED2/24/11
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 0Valley Plat ❑Ridge ❑Other
LATITUDE 34 0°58 '55 " DMS
LONGITUDE 80 ®° 27.31
"DMS
DD
DD
Latitude/longitude source: fit PS [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.)
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
(336 ) 335-3174
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
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 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
Top 5 Bottom 20
Top
Top
Bottom
Bottom
10. SAND/GRAVEL PACK:
Depth
Top 3 Bottom 20
Material
PVC
Method
tremmie
Diameter Slot Size Material
Ft.2 in. .010 in. PVC
Ft. in. in.
Ft. in. in.
Size Material
Ft. Med. Quartz
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0
8
19
/8
/19
/20
/
/
/
/
/.
12. REMARKS:
Formation Description
Red silty clay
weathered rock
rock
A'19 2011
Processir,r, I lr;.
uvvl,t/E3OG
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.
Ax3/4/11
�IGf' TURt OF CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmif within 30 days of corn
ir Mali : Service Center, Ra(eigF
letion to 'Division of Water Quality'
27699 161, Phone [phone]:
Form GW-lb
Rev. 2/09