391926_Well Construction - GW1_20110419

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Bryan Vest
Well Contractor (Individual) Name
Ransier Environmental Drilling
Well Contractor Company Name
PO Box 923
Street Address
Pinehurst
NC 28370
City or Town State Zip Code
( )
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable)MW3
3. WELL USE (Check One Box) Monitoring VMunicipal/Public ❑
Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED11 /16/10
4. WELL LOCATION:
9911 Olive Branch Rd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Marshville COUNTYUnIOn
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑ Flat ❑ Ridge ❑Other
LATITUDE 36 ®° "DMS
LONGITUDE 75 ® ° " DMS
35.103307
80.320726
DD
DD
Latitude/longitude source: ❑GPS [(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.)
Fred Staton's Store
Facility Name
9911 Olive Branch Rd.
Facility ID# (if applicable)
Street Address
Marshville NC 28103
City or Town State Zip Code
State Lead Program
Contact Name
1637 Mail Service Center
Mailing Address
Raleigh
City or Town
NC 27699
State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO E/
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 0 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 0 Bottom 5' Ft. 2 in. sch 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 3' Ft. Portland Pour
Top 3' Bottom 4' Ft. Bentonite Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 5' Bottom 25' Ft. tin in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4' Bottom 25' Ft. coarse Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 1' GRAVEL
1' /6' MUDSTONE
6' / 25' BEDROCK
/
/
/ I ,6^ a 117 It
/ [iii P. 1 b 7011
12. REMARKS:
Infnrmati. fe, r., .. .. ,.flO Unit
DWC: TOG
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.
11 /17/10
SIGNURE OF CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
bmit within 30ndays of completion to
7 Mall Service Center, Raleigh, NC 27699
one
lateti Quali;
919),807 63.
ormationProcessin
Form GW-1 b
Rev. 2/09