405539_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
3242 POTTERS HILL RD
Street Address
PINK HILL NC 28572
City or Town State Zip Code
( 252 ,) 568-2380
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 121
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Rf
DATE DRILLED 3-28-11
TIME COMPLETED 3:30 AM O PM El
4. WELL LOCATION:
CITY: WALLACE COUNTY DUPLIN
3909 NC 41 S
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LA y' SETTING: (check appropriate box)
DSlope ❑Valley ►, lat D Ridge DOther
LATITUDE ?4'-° 7 42 /JL9q = "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 15 7 ° 57 2-1 k46 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: DTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
BILLY DIXON
Owner Name
3909 S NC 41
Street Address
WALLACE
City or Town
(910 ) 285-7939
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 118
c. WATER LEVEL Below Top of Casing: 3
(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.
NC 28466
',State Zip Code
•
JUN 11 2012
b. DOES WELL REPLACE EXISTING WELL? YES D NO Cyc
FT.
e. YIELD (gpm): 42 METHOD OF TEST BLOWED
f. DISINFECTION: Type CLORINE Amount 2-3"PILL6
•
•
•
•
•
•
•
•
•
•
•
•
g. WATER ZONES (depth):
Top 100 Bottom 118
Top Bottom
Top Bottom
7. CASING: Depth
Top + 1 Bottom 108
Top Bottom
Top Bottom
8. GROUT: Depth
Top 0 Bottom 20
Top Bottom
Top Bottom
9. SCREEN: Depth
Top 108 Bottom 118
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top 100 Bottom 118
Top Bottom Ft.
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft 2 SC40 PVC
Ft.
Ft.
Material
Ft. BENTONITE
Ft.
Ft.
Method
POORD
Diameter Slot Size Material
Pt.2 in. 15 in. PVC
Ft. in. in.
Ft. in. in.
Size Material
Ft. MED SAND
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /12
Formation Description
TOPSOIL&SAND
12 / 75 CLAY SAND SHELL MIX
75 / 76
76 / 90
90 /107
107 /108
108 /118
/
2.
REMARKS:
ROCK
CLAY
SANDY CLAY
JUN
120
--1 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.
3-28-11
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,
Form GW-la
Rev. 2/09