406890_Well Construction - GW1_20120711

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 Rd
Street Address
Iron Station
City or Town
( 704 ) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) AS-20
3. WELL USE (Check One Box) Monitoring (e Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery C1 Injection 0
lrrigationp Other 0 (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 Wriahtsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Hanovo
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Valley itFlat 0 Ridge D Other
LATITUDE 34 0 12 712.0000 DMS OR 3X.XXXXxxXXX DD
LONGITUDE 77 ° 51 967.0000 „ DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 6PS Qiopographic 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.)
Former SiotcJ, jpa n #182
Facility Name
5200 Wrightsville Ave
Street Address
Wifrninaton
City or Town
BryafLievre
Facility ID# (if applicable)
NC 28403
State Zip Code
Contact Name
P_0. Box 12Q55
Mailing Address
Wilmipaton NC 28405
City or Town State Zip Code
( 910j6 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO C1
c. WATER LEVEL Below Top of Casing: 8' FT.
(Use "+" if Above Top of Casing)
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 20' Ft. 2" Sch40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 15'. Ft. Portland Trimmie
Top 15' Bottom 18' Ft Bentonite Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 20' Bottom 25' Ft. 2" in. .010 in. PVC
Top Bottom Ft, in. in.
TopBottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 18' Bottom 25' Ft. #2 Silica
: Top Bottom Ft.
: Top Bottom Ft.
:
: 11. DRILLING LOG
Top Bottom Formation Description
0 / 25' Silty Sand
•
•
/
/
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTI • N STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PRHE WE L OWN
SIGNATURE OF CERTIFIED
PRINTED NAME'' PERSO
CNTCT i R . DATE
I G 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-1 b
Rev. 2/09