406556_Well Construction - GW1_20120711

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4108-1
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 : Top 0 Bottom 20' Ft. 2" Sch40 PVC
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) AS-16
3. WELL use (Check One Box) Monitoring V MunicipallPublic 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 Wrightsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Hanove
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope ❑ Valley "Flat ❑Ridge ❑Other
LATITUDE 34 0 12 , 712.0000 „DMS OR 3X.)9x000000X DD
LONGITUDE 77 0 51 , 972.0000 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 61GPS ❑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 Facility ID# (if applicable)
5200 Wriabtsville Av.e
Street Address
Wilminaton
City or Town
Bryan Lievre
Contact Name
P _ 0 . Box 12055
Mailing Address
Wilminaton NC 28405
City or Town State Zip Code
( 910,6 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 8'
(Use "+" if Above Top of Casing)
YES ❑ NO 5/7
FT.
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): NIA 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 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.
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
•
NC 28403
State Zip Code
/
/
12. REMARKS:
•
4,;
► c s i % =
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 PROVID D Ti . H ELL , ' ER.
6 -tql 9
. .„ AI AL,
SIGNATURE OF CERT `' D WELL ONTRAC OR DATE
! �1
•
PRINTED NAME OF PERSON CONSTR CTING 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