406546_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 Dawci, Inc.
Well Contractor Company Name
1006 Camo Creek Rd
Street Address
Iron Station
City or Town
(704 ,) 732-0213
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) AS-6
3, WELL USE (Check One Box) Monitoring Nit Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ injection ❑
IrrigationD Other ❑ (list use)
DATE DRILLED 6-15-12
4. WELL LOCATION:
5200 W ri a h is v i l l e Ave
NC
State
28080
Zip Code
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminciton COUNTY New Hanovn
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ ValleyiiiFlat ❑Ridge ❑Other
LATITUDE 34 ° 12 , 716.0000 "DMS OR 3XJ00000000( DD
LONGITUDE 77 0 51 ► 969.0000 DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: VGPS :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 $cotchman #182
Facility Name Facility ID# (if applicable)
5200,Wrioj,tsvjlle Ave
Street Address
Wilmington NC 28403
City or Town State Zip Code
Bryan Lievre
Contact Name
PD. Box 12055
Mailing Address
Wilminoton NC 28405
City or Town State Zip Code
( 910,6 932-3050
Area code Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 50'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q/
c. WATER LEVEL Below Top of Casing: 8' FT.
(Use '4- 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
g. WATER ZONES (depth):
Top N/A Bottom Top
: Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top 0 Bottom 45' Ft. 2".
: Top Bottom_ Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 40' Ft. Portland
Top 40' Bottom 43' Ft.Bentonite Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter
: Top 45' Bottom 50' Ft. 2" in.
Top Bottom Ft. in.
Top Bottom Ft. in. in.
Amount
Bottom
Bottom
Bottom
Thickness/
Weight Material
Sch40 PVC
Method
Trimmie
Slot Size Material
.010 in. PVC
in.
: 10. SAND/GRAVEL PACK:
Depth Size
Top 43' Bottom 50' Ft. #2
Top Bottom Ft.
: Top Bottom Ft.
Material
Silica
: 11. DRILLING LOG
Top Bottom Formation Description
0 / 5Q' . Silty Sand
/
12. REMARKS:
r7 i;
c 9 @ E
s t € c J
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRU TION STANDARDS, AND THAT A COPY OF THIS
: RECORD HAS BEEN PROVIDE • O , E ELL • NER.
•
SIGNATURE OF CERTIFI
D WEL
6- /4-12
ONTRACTOR DATE
• PRINTED NAM 0 • ERS4CON TING 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