406544_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 Cam!) 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-4
3. WELL USE (Check One Box) Monitoring Cl Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ 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)
❑ Slope DValley itFlat ❑Ridge ❑Other
LATITUDE 34 12 716.0000 DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 O 51 ' 977.0000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: BPS ❑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 Wrightsville Ave
Street Address •
Wilminaton NC 28403
City or Town State Zip Code
Brva n Lj evre
Contact Name
P.O, 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: 50'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO air
c. WATER LEVEL Below Top of Casing: 8' FT.
(Use "+" if Above Top of Casing)
4,
d. TOP OF CASING IS 0 FT. Above Land Surrack'.4., r
• *Top of casing terminated at/or below land surface may require
• a variance In accordance with 15A NCAC 2C .0118.
.
e. YIELD (gpm): NJA 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
Top
Top
Bottom 45' Ft. 2" Sch40 PVC
Bottom Ft.
Bottom Ft.
8. GROUT: Depth Material
: Top 0 Bottom 40' Ft. Portland
Top 40' Bottom 43' Ft. Bentonite
Top Bottom Ft.
9. SCREEN: Depth Diameter
: Top 45' Bottom 50' Ft. 2" in.
Top Bottom
Top Bottom
Method
Trimmie
Pour
Slot Size Material
.010 in. PVC
Ft. in.
Ft. in.
in.
in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 43' Bottom 50' Ft. #2 Silica
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 50' Silty Sand.
12. REMARKS:
` f r~ I
Li • �.
1 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 PROVIDED To T W .' • N
SIGNATURE OF CERTIFI WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRU 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