415200_Well Construction - GW1_20130812

NON RESIDENTIAL 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 NC 27616
City or Town State Zip Code
(919 ) 873-2211
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) N 1l�( 2.
3. WELL USE (Check One Box) Monitoring IV'Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 12/14/12
4. WELL LOCATION:
5210 us 421
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Hanover -
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley Vlat ❑Ridge ❑Other
LATITUDE 34 " DMS oR 19.4141 DD
LONGITUDE 77 " DMS OR 59.1718 DD
Latitude/longitude source: BPS Dfopographic 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 Landfill S o1
Facility Name Facility ID# (if applicable)
5210 US 421
Street Address
Wilmington NC 28403
City or Town State Zip Code
Andy MilIvzy
Contact Name
5210 US 421
Mailing Address
Wilmington NC 28403
City or Town
( 910.Q 508-2960
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO V
c. WATER LEVEL Below Top of Casing: 10.54 FT.
(Use "+" if Above Top of Casing)
Top 7
Top
Top
15200
d. TOP OF CASING IS 3.24 FT. Above Land Surface`
*Top of casing terminated atior 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 10 Ft. 2 inch shd 40 pvc
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 5 Ft. cement
Top 5 Bottom 7
Top Bottom Ft.
Method
trimmie
Ft. bentonite pour
9. SCREEN: Depth Diameter
Top 10
Top
Top
Bottom 20
Bottom
Bottom
10. SAND/GRAVEL PACK:
Depth
Bottom 20
Ft. 2
Ft.
Ft.
Ft.
Bottom Ft.
Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / 20
12. REMARKS:
in.
in.
in.
Slot Size Material
.10 in. pvc
in.
in.
Size Material
Formation Description
tan to brown fine to coarse sand
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 PR Q 5 ED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
I' a•A 44
v4ee,�:4
PRINTED NAME OF PERSON CONSTRUCR e'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