404247_Well Construction - GW1_20120416

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4108-B
1. WELL CONTRACTOR:
William Kicker
Well Contractor (Individual) Name
Mad Dawa, Inc
Well Contractor Company Name
1006 Camp Creek Road
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#. N/A
NC
State
28080
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-17
3. WELL USE (Check One Box) Monitoring 1 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 031101 20 2..
4. WELL LOCATION:
2406 N. 23rd Street - Wilminaton. NC 28401
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Hanov©
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley Flat ❑Ridge ❑Other
LATITUDE 34 15 869.0000 DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 55 ' 160.0000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 12f3PS ❑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.)
Alcoa
Facility Name Facility ID# (if applicable)
2406 N 23rd Street
Street Address
Wilminaton NC 28401
City or Town State Zip Code
Tim Grant
Contact Name
5900 Triangle Drive
Mailing Address
Raleiah NC 27617
City or Town State Zip Code
( 919,15 740-0172
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12'
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO qI
'1'04 7
d. TOP OF CASING IS 0 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): N/A METHOD OF TEST
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 2' Ft. 2" sch40 PVC
: Top Bottom Ft.
Top Bottom Ft.
:8. GROUT: Depth Material Method
Top 0 Bottom 1' Ft. Portland Trimmie
: Top 1' Bottom 1'6" Ft. Bentonite Pour
Top
Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top 2' Bottom 12' Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 1'6" Bottom 12' Ft. #2 Silica
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
0 / 12'
/
/
/
/
/
12. REMARKS:
Formation Description
Gray Silty Sand, some Clay
A ',IP 4
NT. 2
lorrvirnAtingt Prowlossinigoit
CRINCYBOG
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.
• !DI f,
SIGNATURE OF CERTIFIED WELL CONTRACTOR iAT
William Kicker ���...^�,�-a�,.,..y ��-.T .� ._--- � _�;
s ���-�� j
PRINTED NAME OF PERSON CONSTRUCTING titmE WELL :_
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Submit within 30 days of completion to: Division of Water Quality - Information Processing,r,1 APR
Rev. 2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
c. WATER LEVEL Below Top of Casing: 2
(Use "+" if Above Top of Casing)
FT.

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