405935_Well Construction - GW1_20120625

1 4 ESI ENTIAL WELL CONST REC
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONT
1. WELL CONTRACTOR:
Bobbie Fowler
CTOR CERT1IF CATION # '
Well Contractor (Individual) Name
Mid -Atlantic Drillinq Inc.
Well Contractor Company Name
PO Box 315
Street Address
Carolina Beach
City or Town
(910 ) 458-5020
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28428
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) /A
SITE WELL ID #(if applicable) M W-1
3. WELL USE (Check One Box) Monitoring c` Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 5-18-12
4. WELL LOCATION:
3912 Cherry Ave.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY N.H.0
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley nFlat 0 Ridge ❑ Other clty
I I-ST CD 34 wiv^ ^ ;t: 9,n0oo'oA ! CL R OR 310XXXX x90xx CC
KNMF I$TCD 77 lie` `,`^& UNN'! CL R OR ht.5606=106M CC
Latitude/longitude source: DGPS ❑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.)
Green Street II. MC N/A
Facility Name
3912 Chem Ave.
Street Address
Wilmington
City or Town
William Clewis
69=A
ro.
d. TO OF CASING IS 0.25 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): METHOD OF TEST
f. DISINFECTION: Type Amount
▪ g. WATER ZONES (depth):
: Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 7 Ft. 2"
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 2 Ft. Cement
Top 2 Bottom 5 Ft. Bentonite
Top Bottom Ft.
Method
9. SCREEN: Depth Diameter Slot Size Material
: Top 7 Bottom 17 Ft. 2 in. in.
i Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Size Material
Top 5 Bottom 17 Ft. Sand
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
0 /10
Facility ID# (if applicable) 10 / 17
Contact Name
3804 Peachtree Ave. STE .. 220
Mailing Address
Wilminaton
City or Town
256-3188
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 17
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 10
(Use "+" if Above Top of Casing)
NC
State
NC
State
28403•
/
Zip Code :•
/
•
/
/
28403
Zip Code
YES ❑ NO 5/
FT.
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
•
•
12. REMARKS:
Backfill Material
Light Brown Sand
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED (AC` ORDOIC WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY Ot THIS
: R RD UAS EEN PROVIDED TO THE WELL OWNER.
,.
(\ el
• /"ate`` 0'a. �r •l`!Y4 w.wmn
• SI ATURE OF CERTIFIED WELL€0NTRACTOR
Bobbie Fowler
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
JUN 2 5 2012
Form GW-1 b
Rev. 1/08
5-18-12
DATE.
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]