405532_Well Construction - GW1_20120611

1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2616-A
JIMMY S QUINN
Well Contractor (Individual) Name
QUINNS WELL DRILLING
Well Contractor Company Name
Street Address
3242 POTTERS HILL RD. NC 28572
City or Town State Zip Code
( 252) 568-2380
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 171
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply [
DATE DRILLED 10-6-11
TIME COMPLETED 4:30 AM D PM [i(
4. WELL LOCATION:
CITY: BEULAVILLE COUNTY DUPLIN
112 JOHNNY WHALEY LN
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope En/alley iii'Flat 0 Ridge D Other
LATITUDE '° ' 2- " DMS OR 3x.)00xxxxxxx DD
a t r
LONGITUDE 1 ° 72 ' e 2- " DMS OR 7X.Xxxxxxxxx DO
Latitude/longitude source: BPS []Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
MICHAEL WAGONER
Owner Name
112 JOHNNIE WHALEY LN
Street Address
BEULAVILLE
City or Town
[phone]
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 195
State
28572 _ .
Zip Code
JUN 11 2Oi2
b. DOES WELL REPLACE EXISTING WELL? YES D NO Li
c. WATER LEVEL Below Top of Casing: 43 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS +1 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): 15 METHOD OF TEST BLOWED
f. DISINFECTION: Type CLORINE Amount 2-3"PILL
Top 175
g. WATER ZONES (depth):
Top 180 Bottom 195 Top Bottom
Top Bottom Top Bottom
Top Bottom. Top Bottom
Thickness/
7. CASING: Depth Weight Material
Top +1 Bottom 180
Top Bottom
Top Bottom
Diameter
Ft. 2
Ft.
Ft.
SC40 PVC
8. GROUT: Depth Material
Top O Bottom 20 Ft. BENTONITE
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 180
Bottom 195
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth Size
Bottom 195 Ft. M E D
Method
POORED
Diameter Slot Size Material
Ft.2 in. 15 in. PVC
Ft. in.
in.
Ft. in. in.
Top Bottom _ Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /12
12 /29
29 /65.
65 /138
138 /141
141 /170
170 /172
172 /178 •
178 /180
180; /195
12: , 'REMARKS:
Material
SAND
Formation Description
YELLOW -SAND
YELLOW CLAY
SAND -CLAY MIX
HARD BLUE CLAY
ROCK
SOFT CLAY & SAND
ROCK
CLAY
ROCK
RECEIVE[?
WATER SAND
.31 N t)
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.
10-7=11
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
JIMMY S QUINN
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
1
Form GW-la
Rev. 2/09
tUlowit