406543_Well Construction - GW1_20120711

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality ' 'f sit
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WELL CONTRACTOR CERTIFICATION # 4108-B
1. WELL CONTRACTOR:
William Kicker
Well Contractor (Individual) Name
Mad Dawci. Inc.
Well Contractor Company Name
1006 Camp Creek Rd.
Street Address
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 Amount
g. WATER ZONES (depth):
Iron Station NC 28080 : Top N/A Bottom Top Bottom
City or Town State Zip Code : Top Bottom Top Bottom
(704 ) 732-0213 : Top Bottom . Top Bottom
Area code Phone number
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# N/A : Top 0 Bottom 4� Ft. 2" Sch4O PVC
•
OTHER ASSOCIATED PERMIT#(if applicable) N/A : Top Bottom Ft.
SITE WELL ID #(if applicable) AS-3 : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring Nit Municipal/Public ❑ 8. GROUT: Depth Material Method
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection ❑ : Top 0 Bottom 40' Ft Portland Trimmie
Irrigation❑ Other ❑ (list use) : Top 40' Bottom 43'. Ft Bentonite Pour
DATE DRILLED 6-15-12 : Top Bottom Ft
4. WELL LOCATION: : 9. SCREEN: Depth Diameter Slot Size Material
5200 Wrightsville Ave : Top 45' Bottom 50' Ft. 2" in. .010 in. PVC
(Street Name,'Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Top Bottom Ft. in. in.
CITY: Witminoton COUNTY New Hanove : Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope DValley VFlat ❑ Ridge DOther
LATITUDE 34 012 ' 710.0000 DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 51 , 981.0000 ,► DMS OR 7X,XXXXXXXXX DD
Latitude/longitude source: PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
10. SAND/GRAVEL PACK:
Depth Size Material
Top 43' Bottom 50' Ft. #2 Silica
•
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
5. FACILITY (Name of the business where the well is located.) : Top Bottom Formation Description
Former Scptchman #182 • 0 / 50' Silty Sand
Facility Name Facility ID# (if applicable) : /
5200 WriahtsvilJe Ave /
Street Address .• /
lgton , NG 2840 /
Wimin
City or Town State Zip Code : /
Bryan Lievre •/
Contact Name : /
P_0. Box 12055 •
Mailing Address ' /
Wilmington NC 28405 /
City or Town State Zip Code
12. REMARKS:
( 910,6 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 50'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [i'
c. WATER LEVEL Below Top of Casing: 8' FT.
(Use "+" if Above Top of Casing)
E
' •tiLV.• w.. 44
I DO 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 T0,THFrW L OWNER.
' `d
SIGNATURE OF CERTIFIED COR DATE
/ne,
PRINTED NAOF PERSON CONSTRUCTINTHE 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