406541_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
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-1
3. WELL USE (Check One Box) Monitoring El Municipal/Public 0
Industrial/Commercial 0 Agricultural D Recovery p Injection 0
Irrigationo Other 0 (list use) ,
DATE DRILLED 6--1 5-12
4. WELL LOCATION:
5200 Wrightsville Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilrninaton COUNTY New Hanove
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope ❑ Valley kiFtat p Ridge ❑ Other
LATITUDE 34 ° 12 ' 707.0000 " MS OR 3X.XxxxxxxxX DD
LONGITUDE 77 ° 51 ' 987.0000 ° DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: V3PS :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 Scotch man #182
Facility Name
5200 Wfia htsvj l ie Ave
Facility ID# (if applicable)
Street Address
Wilminaton NC 28403
City or Town State Zip Code
Bryan ,Lievre
Contact Name
P.O. Box 12055
Mailing Address
Wilmington NC 28405
City or Town State Zip Code
910a . 932-3050
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 50'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 8'
(Use "+" if Above Top of Casing)
YES ❑ NO cit
FT.
d, TOP OF CASING 1S 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):
Top N/A Bottom Top Bottom
: Top Bottom Top
Top Bottom Top
Bottom
Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0. Bottom 45' Ft. 2" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 40' Ft. Portland Trimmie
Top 40' Bottom 43' Ft. Bentonite Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 45' Bottom 50' Ft. 2" in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. 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
• • 0 / 5Q'
•
/
:•
•
•
•
12. REMARKS:
Formation Description
Silty Sand
i
. .
r .�:. . .
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STAND RDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PRpVID2D SO THE WE OWNER.
6-
SIGNATURE OF CERTIFIED ELL CONTRACTOR DATE
7
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-16/, Phone : 9•19) 807-6300
Form GW-1 b
Rev. 2/09