406558_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 Dawg, 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-18
3. WELL USE (Check One Box) Monitoring i Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 Wrightsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Hanove
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
C1 Slope ❑ Valley elat 0 Ridge D Other
LATITUDE 34 ° 12 ' 717.0000 "DMS OR 3X.XXXXXXXxX DD
LONGITUDE 77 ° 51 968.0000 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: VPS ❑Topographic 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. Scotchman #182
Facility Name
5200 Wriahtsville Ave
Facility ID# (if applicable)
Street Address
Wilminaton NG 28403
City or Town State Zip Code
Bryan Lievre
Contact Name
P.O. Box 12055
Mailing Address
Wilmington NC _ 28405
City or Town State Zip Code
( 91 On 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25'
b. DOES WELL REPLACE.EXISTING WELL? YES 0 NO Lit
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
Top 0 Bottom 15'
Material
Ft. Portland
•
Method
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.
Top Bottom 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 CONSTRUCTION STANDAR'S, AND THAT A COPY OF THIS
: RECORD HAS BEE 'ROVID D T•/ HE 'SELL R.
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
RACTOR DATE
-e/V
THE WELL
Form GW-1 b
Rev. 2/09