391925_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
(910 ) 690-6688
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable)MW4
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ 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 0 ° " DMS
LONGITUDE 75 ® ° " DMS
35.103307
DD
80.320726 DD
Latitude/longitude source: DGPS Cropographic 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
City or Town
State Lead Program
NC 28103
State Zip Code
Contact Name
1637 Mail Service Center
Mailing Address
Raleigh NC 27699
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25'
b. DOES WELL REPLACE EXISTING WELL?
YES ❑ NQ Cif
c. WATER LEVEL Below Top of Casing: FT.
(Use °+" if Above Top of Casing)
d. TOP OF CASING IS 0 FT. Above Land S&`be*
*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
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
Amount
Bottom
Bottom
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
Top 0 Bottom 3' Ft, Portland
Top 3' Bottom 4' Ft. Bentonite
Top Bottom Ft.
9. SCREEN: Depth
Top 5' Bottom 25'
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top 4' Bottom 25'
Method
Pour
Pour
Diameter Slot Size Material
Ft.2in in. .010 in. PVC
Ft. in. in.
Ft. in. in.
Size Material
Ft. coarse Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0
1'
6'
/ 1'
/ 6'
/ 25'
12. REMARKS:
Formation Description
GRAVEL
MUDSTONE
BEDROCK
WM 1
� Ini4
nfntnlatitl�;
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
SI� c F CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit within'30 days of completion to
17: Mail Service Center, Raleigh, NC 27699
tvtslon of Water QOil!
one (919) 807-63i
orrration''
Form GW-lb
Rev. 2/09