406555_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-15
3. WELL USE (Check One Box) Monitoring ri Municipal/Public D
Industrial/Commercial D Agricultural 0 Recovery D Injection D
Irrigation❑ Other D (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 Wriahtsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Hanovo
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope DValley FiFfat ❑ Ridge D Other
LATITUDE 34 012 ' 712.0000 ,► DMS OR 3X.xxxxxXxxX DD
LONGITUDE 77 0 51 i 976.0000 ° DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: VIGPS Dfopographic map •
(location of well must be shown on a USGS topo map and'attached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Former Scotchrnan #182
Facility Name
5200 Wriahtsville Ave
Facility ID# (if applicable)
Street Address
Wilminaton , • NC 28403
City or Town State Zip Code
Bryan Lieyre
Contact Name
P.O. Box 12055
Mailing Address
Wilminattn NC 28405
City or Town State Zip Code
(. 910n 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 q/
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 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.
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
1
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12. REMARKS:
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STAN 'ARDS, AND THAT A COPY OF THIS
: RECORD HAS BEEN PROVIDED T HE WL OWNER.
-I 02
• SIGNA URE OF CERTIFIED L C • ' T' ' TOR DATE
• /76-4A,4c,
• PRINTED NAM OF PERSON CONSTR 1CTING 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