403756_Well Construction - GW1_20120316

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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
( 919 )_ 233-8626
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-1
Zip Code
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 2/7/2012
TIME COMPLETED 10:30 AM E PM ❑
3. WELL LOCATION:
CITY: Wilmington COUNTY New Hanover
3602 Winston Blvd. 28403
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope fi Valley j Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 3 4.22548°
W77.89588°
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑ GPS ® Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME Tom Hayes
STREET ADDRESS Turtle Trail Holdings, Inc., PO Box 632
Wilmington
NC 28480
City or Town State Zip Code
( 919 )_ 233-8626
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 23'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO E
c. WATER LEVEL Below Top of Casing: 18.89 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
6. CASING:
fy'
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
Thickness/
From 0 DepthTo Ft.2Diameter -S� 40 Material
VC rial
From To Ft.
From To Ft.
7. GROUT: Depth
Material Method
From 0.3 To 3 Ft. portland poured
From 3 To 11 Ft. bentonite poured
From To
Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 13 To 23 Ft.2 in. 0.01 in. PVC
From To Ft. in. in.
From To Ft. in. in.
SAND/GRAVEL PACK:
Depth Size Material
From 11 To 23 Ft. #2 . Filter Sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To
0 8'
8' 16'
16' 23'
11. REMARKS:
Formation Description
Tan sand
Gray sand
White sand
UnYt
p roce55in
OG
I DO HEREBY CERTIFY THAT THIS WELL WAS (VAMRUCTU\ICORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A C. Y OF THIS
RECORD HAS BEEN PROVIDED TO THE WE I.JR OWNER.
RE \\10 S '0
SIG •1—ZEN'CYFTERTIFlp WELL ►.NTRTOR DA
lodhefr=r-
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-la
Rev. 7/05

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t4.25000°
t•.21667°
NATIONAL
E GRAPHIC
77.90000° W
0.0
0.0 0.5
0.5 miles
1.0 km
WGS84 77.88333° W
WGS84 77.88333° W
MN*TN
9°
03/13/12
C4.25001°
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