415201_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 Dugqins
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) NV-1
3. WELL USE (Check One Box) Monitoring A/Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/14/12
Recovery ❑ Injection 0
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 Mat ❑ Ridge ❑ Other
LATITUDE 34 ° " DMS OR 19.3971 DD
LONGITUDE 77 ° " DMS OR 59.3186 DD
Latitude/longitude source: liPS ['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 6 C--09
Facility Name acility ID# (if applicable)
5210 US 421
Street Address
Wilmington
City or Town
Andy Mglvey
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
NC 28403
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Li/
c, WATER LEVEL Below Top of Casing: 21.78 FT.
(Use "+" if Above Top of Casing)
52O1
d. TOP OF CASING IS 2,89 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
Top Bottom Top
Top Bottom Top
Bottom
Bottom
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
Top 0 Bottom 15 Ft. cement
Top 15 Bottom 17 Ft. bentonite
Top Bottom Ft.
9. SCREEN: Depth
Top 20 Bottom 30
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top 17 Bottom 30
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0 / 30
/
/
12. REMARKS:
-NVIf=1
Method
trimmie
pour
Diameter Slot Size Material
Ft. 2 in. .10 in. pvc
Ft. in. in.
Ft. in. in.
Ft.
Ft.
Ft.
Size Material
Formation Description
tan to brown fine to coarse sand
TMEMITSZTRIMI
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FORM ( Y. 4 ' . tt� �Jr4r
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL C• NSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HA 0 THE WELL OWNER.
SIGNATURE OF ERTIFIED WELL CONTRACTOR
PRINTED NAME OF PERSON COgI.TCTING 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