406545_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. 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-5
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 Wriahtsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton couNTY New Hanove
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
o Slope :Walley 'Fiat 0 Ridge ❑ Other
LATITUDE 34 ° 12 ' 709.0000 DMS OR 3X.xxxxxXXXX DD
LONGITUDE 77 ° 51 , 975.0000 DMS OR 7X.XXXXXX000X 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 Scotchma.n #182
Facility Name Facility ID# (if applicable)
5200 Wriahtsyille Ave
Street Address
Wilmington NC 28403
City or Town State Zip Code
Bryan Lievre
Contact Name
P.O. Box 12055
Mailing Address
Wilminaton NO 28405
City or Town State Zip Code
( 910 ,n 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 50'
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO 5%
c. WATER LEVEL Below Top of Casing: 8' FT.
(Use "+" if Above Top of Casing)
d
•e
f
.
:f.
•
. 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.
. YIELD (gpm): NIA METHOD OF TEST
DISINFECTION: Type N/A Amount
. 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 45' Ft. 2" Sch40 PVC
: Top Bottom
Top Bottom
8. GROUT: Depth
Top 0 Bottom 40'
Top 40' Bottom 43' Ft. Bentonite
Top Bottom Ft.
Ft.
Ft,
Material
Ft. Portland
9. SCREEN: Depth Diameter
Top 45'
• Top
Top
Method
Trimmie
Pour
Slot Size Material
Bottom 50' Ft. 2" in. .010 in. PVC
Bottom Ft in. in.
Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top 43'
Top
: Top
: 11. DRILLING LOG
Top Bottom
0 / 50'
12. REMARKS:
Size Material
Bottom 50' Ft. #2 Silica
Bottom Ft.
Bottom Ft.
Formation Description
Silty Sand
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION S ANDARDS, AND THAT A COPY OF THIS
: RECORD HAS BEEN PROVIDE Q TO, 1 ELL OWNER.
SIGNATURE
CERTIFIE
N RAC -TOR D-yq
ATE
: PRINTED NAM
F PERSON CONSTR ING 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