409742_Well Construction - GW1_20121217

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2595
1. WELL CONTRACTOR:
Alton Boshoff
Well Contractor (Individual) Name
Geo Support, Inc.
Well Contractor Company Name
STREET ADDRESS 5216 Yates Mill Pond Rd
Raleigh, NC 27606
City or Town State Zip Code
( 919 )_ 233-8626
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-1
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 11/1/2012
TIME COMPLETED 4:30 AM ❑ PM El
3. WELL LOCATION:
CITY: Wilmington COUNTY New Hanover
3729 Winston Blvd.
28403
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley E] Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 3 4.22558°
LONGITUDE W77.89241°
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑ GPS ® Topographic map
(location,ofwell must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME Steve Midway
STREET ADDRESS 3729 Winston Blvd.
Wilmington
NC 28403
City or Town State Zip Code
( 919 )_ 233-8626
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 11'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 8.82 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS NA 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
409
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
0 Depth 2Diameter V180 Material
From To Ft.
PVC
From To Ft.
From To Ft.
7. GROUT: Depth Material
From 0.3 To 3 Ft. portland
From 3 To 4 Ft. bentonite
From To Ft.
Method
poured
poured
8. SCREEN: Depth Diameter Slot Size Material
From 6 To 11 Ft.2 in. 0.01 in. PVC
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From 4 To 11 Ft. #2 Filter Sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 6'
6' 11'
PC
Formation Description
Brown sandy topsoil
Medium white sand
171 r Y
, E
7 "V.
7RE
by ;ai .
Ei
11. REMARKS:
DEC - 7 2012
Information Proct*S`fg Un'
uWO/BOG
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 O R.
SIGNATURE OF CERTIFIED
TRACTOR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-1 a
Rev. 7/05

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11/05/12