415192_Well Construction - GW1_20130812

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3423A
1. WELL CONTRACTOR:
William T Duggins
Well Contractor (Individual) Name
Terracon
Well Contractor Company Name
5240 Green's Dairy rd
Street Address
raleigh
City or Town
(919 ) 873-2211
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 27616
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) ! V kv-
3. WELL USE (Check One Box) Monitoring At/Municipal/Public 0
Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/13/12
4. WELL LOCATION:
5210 us 421
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Hanove c
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley flat ❑Ridge ❑Other
LATITUDE 34 " DMS OR 19.3386
LONGITUDE 77
° " DMS OR 58.8339
DD
DD
Latitude/longitude source: BPS ❑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.)
New Hanover County Landfi l( 6C'0 Y
Facility Name Facility ID# (if applicable)
5210 US 421
Street Address
Wilmington NC 28403
City or Town State Zip Code
Andy /}%tLtve/
Contact Name
5210 US 421
Mailing Address
Wilmington
City or Town
( 910.0 508-2960
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 30
NC 28403
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO cV
c. WATER LEVEL Below Top of Casing: 25.76 FT.
(Use "+" if Above Top of Casing)
A 5192
d. TOP OF CASING IS 2.82 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 Bottom 20 Ft. 2 inch shd 40 pvc
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 15 Ft. cement trimmie
Top 15 Bottom 17 Ftbentonite pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 20 Bottom 30 Ft. 2 in. .10 in. pvc
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 17 Bottom 30 Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / 30
/
/
12. REMARKS:
Formation Description
tan to brown fine to coarse sand
BY'..
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.
SIGNATURE`OFERTIFIED WELL CONTRACTOR
PRINTED NAME OF PERSON CONSTRtrCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09