407243_Well Construction - GW1_20120827

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1. WELL CONTRACTOR:..
Robert Stevens
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2489
Well Contractor (Individual) Name
Parratt-Wolff, Inc.
Well Contractor Company Name
501 Millstone Drive
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
f. DISINFECTION: Type N/A
METHOD OF TEST N/A
Amount N/A
Street Address : g. WATER ZONES (depth):
Hillsborough NC 27278 : Top N/A Bottom Top Bottom
City or Town State Zip Code : Top Bottom Top Bottom
(919 ) 644-2814 : Top Bottom Top Bottom
Area code Phone number
• Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# : Top 0 ' Bottom 3.0 Ft. 1" Sch40 PVC
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable). E2-MW1 R
3. WELL USE (Check One•Box) Monitoring 1 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
IrrigationD Other ❑ (list use)
Top Bottom Ft.
Top Bottom Ft.
i 8. GROUT: Depth Material Method
: Top 0 Bottom 1.0 Ft. Portland Tremie
Top 1.0 Bottom 2.0 Ft. Bentonite Tremie
DATE DRILLED 3/9/12 : Top Bottom Ft.
4. WELL LOCATION: : 9. SCREEN: Depth Diameter Slot Size Material
Riverfront Road : Top 3.0 Bottom 8.0 Ft. 1 in. .010 in. PVC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Top Bottom Ft. in. in.
CITY: Kure Beach COUNTY New Hanov© : Top Bottom Ft.. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley Fitlat ❑ Ridge DOther
LATITUDE 33 0 58 , 764.0000 '' DMS OR 3x.xxxxxxxxx DD
LONGITUDE 77 ° 55 , 59.0000 n DMS •OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS itflopographic 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.)
Fort Fisher Air Force Station
Facility Name Facility ID# (if applicable)
Riverfront Road
Street Address
Kure Beach
City or Town
NC 28449
State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 8.0
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c. WATER LEVEL Below Top of Casing: 3.5
(Use "+" if Above Top of Casing)
FT.
: 10. SAND/GRAVEL PACK:
Depth Size Material
: Top 2.0 Bottom 8.0 Ft. #1 Sand
Top Bottom Ft.
: Top Bottom Ft.
11. DRILLING LOG
: Top Bottom Formation Description
/ No samples taken
3iG 2/72012
12. REMARKS:
,EIVED
AUG 2012
Information pry
cessing Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCT' STANDARDS, AND THAT A COPY OF THIS
REC. AS BEEN PROVIDED T THE WELL OWNER.
:. /-'e 4,-- E.--------. P-6--/z.....,
SIGN TURE OF CERTIF D WELL CONTRACTOR DATE
Robert Stevens
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
Submit within 30 days of completion to:Division of Water Quality Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-1b
Rev. 2/09