WI0600068_Well Construction_20120614

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No ESIDENTML WELL CONSTRUCT96N'RECORD
North Carolina Depvitnenrof C'nvironment and Natural Resource- Die=ision of \Vater Quality
WELL CONTRACTOR CERTIFICATION ION #f � ;� w° 0
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (individual) Name
SAEDACCO Inc .
Well Contractor Company Name
STREET ADDRESS 9088 northfield drive
Fort. Mill.. SC 29715
City or Town State Zip Code
Area code- Phone number
2. WELL INFORMATION: .
SITE WELL ID #(ifapplicable) MW-3
STATE WELL PERMIT#i(if applicable)
DWO.or OTHER.PERMIT #i:(if applicable)
WELL USE (Check .Applicable Box) Monitoring zi Municipal/Public C!
Industrial/Commercial Ll Agriculturat 0 Recovery Ip Injection 0
IrrigationO Other'p (list use)
DATE DRILLED 6-11-12
TINE COMPLETED 2 . AM O PM M
3. WELL LOCATION:
CITY: Fayeteville COUNTY Cumberland
3060 Owens Rd.
(Street Name, Numbers, Community. Subdivision. Lot No.: Parcel,•Trp Code)
TOPOGRAPHIC 1 LAND SETTING:
CiSltipe El Valley, MFlat []Ridge 0 Other
(check appropriate box)
LATITUDE 35.02034 May be in degrees,
minutes, seconds or,
LONGITUDE 78. 89635 in a decimal former
Latitudel(ongitude source: sm GPS ❑Topographic map .
(location, of Ivel! must be shown on a.USGS. topo map and
attached to this form if not using GPS) .
4::FACILITY, is the name of. the business where Iha well is located,
FACILITY 1D #(If applicable)
NAME OF'FACILITY smi ty s Cleaners
STREET ADDRESS 3060 Owens Rd.
F+ayetevaille N.C. 28036
City or Tdwn State Zip Code
CONTACT PERSON
MAILING ADDRESS
City or Town. State Zip Code
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 19. s
b.. DOEs WELL REPLACE EXISTING WELL? YES o NO83
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS
FT. Above Land Surface.
*Top'of casing terminated atlor- below'land surface may require
a variance in accordance with 15A NCAC 2C :0118.
e. YIELD (gprn):
METHOD -OF TEST
f. DISINFECTION: Type
Amount.
9. WATER ZONES (depth):,
From To
From To
From To
From To
From To
From To
6. CASING:
Thickness/
Depth
Diameter Weight Material.
From 0 To 9.5
Ft. '2 40 Pvc
From To
Ft.
From To
Ft.
7. GROUT: Depth
Material. Method
From 5.5 To 0
Ft. Portland Pour
From To
Ft..
From To
Ft.
8. SCREEN: Depth
Diameter Slot Size Material
From 9.5 To 19. s
Ft. 2 in.. .1 o in. Pvc
From To______
Ft.,;_in. _ in.
From To
Ft, in. in.
9. SAND/GRAVEL PACK:
Depth
Size Material
From 7.5 To 19.5
Ft. #2 sand
From To—
Ft.�
From To
Ff. -
10. DRILLING LOG
From To
Formation Description
0 19.5
Sand
ti
Jl J N 8, iL
11. REMARKS: � NP-1 F
100 HEREBY; CERTIFY THAT THIS WELL WAS CONST� CORDANCE WITH
=C 15A NCACWELL CONSTRUETION STANDARDS; A Y OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
6.14.12
OF CERTIFIED WELL CONTRACTOR DATE
Randy Hoffman,
PRINTED NAME OF PERSON CONSTRUCTING THE
Submit the original to the Division of Water Quality within 30 days. Attn: Information.M9t., Form GW-1b
1617 Mail Service Center —Raleigh, NC 27699.1617 . --Phone No. [phone] ext 668. Rev. 7105

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North Carolina Depaittnent of Environment and Natural Resources- Division of Water Quality'
WELL CONTRACTOR C'.ERTIFUC AT'90N # 3166
;. WELL CONTRACTOR:
Kelvin Hatt
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9088 Northfield Dr.
Fort Mill Sc 29707
City or Town State Zip Cdde
803 )- 548-2180
Area code- Phone number
I WELL INFORMATION:
SITE WELL ID #(if applicable) MW-30
STATE WELL PERMIT#(if applicable)
DWO or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring N Municipal/Public r_i
Industrial/Commercial C7 Agricultural d Recovery E3 Injection `J
IrrigattonO Other 0 (list use)
DATE DRILLED 6-6-12
TIME COMPLETED AM 0 PM IP
3. WELL LOCATION:
CITY: Fayetteville - COUNTY Cumberland
3060 Owens Rd.
(Street Name, Numbers, Community. Subdivision. Lot No.. Parcel, Zip Code)
TOPOGRAPHIC /LAND SETTING:
oSlope ❑Valley MFlat oRidge L Other
(check appropriate box)
LATITUDE 35.02034 May be in degrees,
minutes. seconds or
LONGITUDE 78.89635 in a decinfat lbrntat
Latitudetlongitudesource: mCiPS oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY• is the name 01,, the business where the well is localed.
FACILITY ID #!(If applicable)
NAME OF FACILITY Smutty, s Cleaners
STREETADDRESS 3060 Owens Rd.
Fayetteville N.C. 28036
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 65
b, DOES WELL REPLACE EXISTING WELL? YES ❑ NO Z3
c. WATER LEVEL Below Top of Casing: FT,
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
`fop 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
n. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 60 Ft. 2 SCH 40 PVC
From 0 To 33 Ft. 1 SCH 40 PVC
From To Ft.
7. GROUT: Depth Material Method
From 0 To 29 Ft. Portland Trimie
From To Ft.
From TO Ft.
0. SCREEN: Depth Diameter Slot Size Material
From 65 To 60 Ft.2 in. olo in. Pvc
From 43 T033 Ft.1 in. .010 in. PVC
From To Ft, in. - in.
9. SAND/GRAVEL PACK:
Depth Size Material
Frain 65 TO 58 Ft #2 Sand
From 43 TO 31 Ft. #2 Sand
From To Ft.
10. DRILLING LOG
From To Formation Description
0 20 Sand
20 65 Silt
�,g� ;,_: [ - 'ice: i : d' �- -•
65
,ll N �UiL
11. REMARKS:
Bentonite pellets placed between deep and shallow
fn)fff�,Nml o r-frr-;,
L� U Nil U U--- li W u
100HEREBY CERTIFY THAT THIS WELL'WASCONSTRUCTE[Ja, ,kCCQRDAN£E�1tITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND TH.AMIAICopY OF,T[iij,2
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
16�)J2i(l12
SIGNAL URE OF CERTIFIED WELL CONTRACTOR s �" 6ATE
Kelvin Hatt
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt„ Form GW-1b
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ent 568. Rev. 7/05

ON RESIDENTYAL WELLCONS-FRUCT0a_,i RECORD
Worth Carolina Dep ulment of E nvironment and Natural Resources- Division of \ ater Quality
WELL (CONTRACTOR CElR.TIIiERt< AT UON 9 3166
1. WELL CONTRACTOR -
Kelvin Hatt
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9088 Northfield Dr.
Fort Mill Sc 29707
City or TNjn State Zip Code
803-5 8-2180
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-31
STATE WELL PERMIT#(if applicable)
DWO or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring -M MunicipalJPublic I-!
Industrial/Commercial n Agricultural C-i Recovery CI Injection ❑
Irrigationo Other C (list use)
DATE DRILLED 6-7-12
TIME COMPLETED AM D PM l
3. WELL LOCATION:
CITY: Fayetteville COUNTY Cumberland
3060 Owens Rd.
(Street Name, Numbers, Community, Subditdsion. Lot No.. Parcel, Zip Code)
TOPOGRAPHIC f LAND SETTING:
❑Slope oValley MFlat CiRidge a Other
(check appropriate box)
LATITUDE 35.02034 Muy N in degrees,
minutes, seconds or
LONGITUDE 78.89635 in a decilmll Ibrinat
Latitudeflongitudesource: mGPS EiTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY• is the name ol the business where the well is located.
FACILITY ID #(If applicable)
NAME OF FACILITY Smitty, s Cleaners
STREET ADDRESS 3060 Owens Rd.
Fayetteville N.C. 28036
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 69
b. DOES WELL REPLACE EXISTING WELL? YES Q NO Ya
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atfor 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):
From To From To
From To From To
From To From To
S. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 59 Ft, 1 SCH 40 PVC
From 0 To 39 Ft. 1 SCH 40 PVC
From 0 To 12 Ft. 1 SCH 40 PVC
7. GROUT: Depth Material Method
From 0 To 8 Ft. Portland Pour
From To Ft.
From To Ft._____
8. SCREEN: Depth Diameter Slot Size Material
From 69 To 59 Ft.1 in, olo in. PVC
From49 T039 Ft.1 in. .010 in. PVC
From 22 To 12 Ft. 1 in. --010 in, PVC
9. SAND/GRAVEL PACK:
Depth Size Material
From 69 TO 57 Ft #2 Sand
From 48 TO 37 Ft. #2 Sand
From 21 To 10 Ft. #2 Sand
10. DRILLING LOG
From To Formation Description
0 20 Sand
20 69 Silt
69
11. REMARKS: `
Bentonite pellets placed between screens.
100 HEREBY CERnFY THAT THIS WELL WAS CONSTROCTE01W,¢gCOf jDANCE-lIf IT'
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, APdH T AIC.OPY- EJI; I hsv
RECORD HAS BEEN PROVIDED TO THE WELL OWNER L�� ill U
— i ti flfl fl➢ °6G?aY Moll
SIGNAL"URE OF CERTIFIED WELL CONTRACC u '' O+'-�IsE'
Kelvin Hatt
PRINTED NAME OF PERSON CONSTRUCTING T % E
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,, Form GW-1b
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev, 7/05

r
a
North Carolbia i)cpaiiment of f ttvironiiient attd N,itural Kesources- Division of %k'ater Quality
WELL CONTRACTOR CERTI FttC:A'i'ION # 3166
1. WELL CONTRACTOR:
Kelvin Hatt
Well Contractor (individual) Name
SAEDACCO Inc
Well Contractor Company Name .
STREET ADDRESS 9088 Northfield Dr.
Fort Mill SC 29707
City or Town- State. Zip Code
80{ 3 )- 548-2180
Area code Phone number
a. WELL INFORMATION:
SrrE WELL iD #(if applicable) MW-32
STATE WELL PERMIT#(if applicable)
OWQ or OTHER PERMIT #(if applicable)
WELL USE (Check. Applicable Box) Monitoring N MunicipallPublic r
Industrial/Commercial e Agricultural C Recovery G Injection
Irtigationp Other [t (list use)
DATE DRILLED 6-8-12
TIME COMPLETED 2 AM O. PM Lx?
3. WELL LOCATION:
CITY: Fayetteville COUNTY Cumberland
3060 Owens Rd.
(Street Name, Numbers, Community. Subchision. Lot No., Parcel, Zip Code) . .
TOPOGRAPHIC /"LAND SETTING:
LISlope [Valley MFlal oRidge E3 Other
(check appropriate box)
LATITUDE 35 : 02034 May be in degrees,
minutes. seconds or
LONGITUDE 78-.89635 in a.decimal,'onnat
Latitudejongitiideso6rce: mGPS t7Topographietitap
(lacatOn of.'we/l.must be shown on a USGS topo 4nap and
attached to 6 S form if not using GPS)
4. FACILITY• is the naine of the business where the well is located.
FACILITY ID #(if applicable)
.NAME -OF FACILITY Smitty's Cleaners
STREET ADDRESS 3060 Owens Rd.
Fayetteville' N.C:'- 26036
City. or Town State Zip Code.
.CONTACT PERSON
MAILING ADDRESS.
City or Town, State Zip Code
Area code - Phone number
5.•WELL DETAILS:
a. TOTAL DEPTH.' 20
b. DOES WELL REPLACE EXISTING WELL4 YES C:, NO w
c. WATER LEVEL Below Top of Casing: FT.
(Use 'V if Above Top of Casing)
l r,.
d. TOP OF CASING IS FT. Above Land Surface
'Top.of casing terminated.atfor below land surface may.require
a variance in accordance with 15A NCAC 20.0118.
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type '.Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: ,Thickness/
Depth Diameter Weight Material .
From 10 TO 0 Ft. 2 40 PVC
From To Ft.
From To Ft.
7. GROUT: Depth Mated6t . Method
From 6 To 0 Ft.:Portland Pour
From To Ft.
From To Ft.
8. SCREENi Depth Diameter Slot Size Material
From 20 To io 'Ft. 2 In. i0 in. Pvc
From To Ft: in. in.
From To Ft. in. � in. �.-..
S. SAND/GRAVEL PACK:
Depth Size Material
From 20 To 8 Ft. #2 sand
From 'To Ft.�
From To Ft.
10. DRILLING LOG
From To Formation Description
0 20 Sand
r3 r U 1 z
11..REMARKS:
-a. m ..
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED 1N AOCORDANCE WITH
15A NCAC2C, WELL CONSTRUCTION STANDARDS, AND TRI��OP� Q� T�
RECORD HAS BEEN PROVIDED TO THE WELL OWNER. V jY�
6/10/2012
SIGN-A-IWU'^R-t, OF GERTIFIED WELt CONTRACT D TE
Kelvin Hatt
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Stlbmit.the original to the Division of Water Quality within 30 days. Atitn' Information Mgt.,
1617 Flail Service Cenier- Raleigh, Nk 27699-160 Phone No. (919) 733.70'IS ext 668.
Form GkN-1b
Rev. 7105