409734_Well Construction - GW1_20121210

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3470-A
1. WELL CONTRACTOR:
William M Wiggins
Well Contractor (Individual) Name
Mid -Atlantic Drillina Inc.
Well Contractor Company Name
PO Box 315
Street Address
Carolina Beach
City or Town
(910 ) 458-5020
NC 28428
State Zip Code
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): METHOD OF TEST
f. DISINFECTION: Type Amount
▪ g. WATER ZONES (depth):
Top Bottom Top
: Top Bottom Top
Top Bottom Top
Bottom
Bottom
Bottom
Area code Phone number Thickness/
2. WELL INFORMATION: ; 7. CASING: Depth . Diameter Weight Material
WELL CONSTRUCTION PERMIT# N/A : Top 0 Bottom 14 Ft. 2" Sch 4C PVC
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-2
3. WELL USE (Check One Box) Monitoring Iv� Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/12/2012
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Material Method
Top 6 Bottom 12 Ft. bentonite pour
Top 0 Bottom 6 Ft. concrete pour
Top Bottom Ft.
4. WELL LOCATION: : 9. SCREEN: Depth
1002 N. 3rd Street : Top 14
= Top
CITY: Wilminaton COUNTY N.H.0 : Top Bottom
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
CJ Slope [Valley Flat ❑ Ridge DOther
KKFSTCD 34 i 44AA�'*"13AAA! CL R OR '3X'AXXX t XX CC
F4\1MF FSTCD 77 i ^n^&4 00`^^! CL R OR 7`X! ' XIOM CC
'Latitude/longitude source: ❑GPS Q 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.)
Liahthouuse Tract 1 N/A
Facility Name Facility ID# (if applicable)
1002 N. 3rd Street
Street Address
Wilminafon NC 28401
City or Town State Zip Code
Bill Henderson
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Contact Name
1117 Military Cutoff Road
Mailing Address
Wilmington N.0 28405
City or Town State Zip Code
( 910,E 509-3909
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 24
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: 17.99
(Use "+" if Above Top of Casing)
q NO /
FT.
Diameter Slot Size Material
Bottom 24 Ft. 2 in. 0.01 in. pvc
Bottom Ft. in. in.
Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top 12 Bottom 24
: Top
: Top
: 11. DRILLING LOG
Top Bottom
•
• 0 /7
•
• 7 /19
•
19 / 24
•
Bottom
Bottom
/
12. REMARKS:
Size Material
Ft. #2 torpedo sand
Ft. natural pack
Ft.
Formation Description
Brown and oragnge medium sans
Tan and gray medium sand
Brown and gray medium sand
9,n12_
PilaCeSSing
sue.
I 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 BEE ►. PROVIDED TO THE WELL OWNER.
�#16 10/23/12
S NA OF CERTI ` ED WEL C TOR DATE
: William M. WiNins
PRINTED NAME OF PERSON CONSTRUCTINGTPit,:— IE
,• t,
Submit within 30 days of completion to: Division of Water Quality Information Processing
1617 Mail Service Center., Raleigh, NC 27699-161, Phone .: [phone]
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11
DECOFInw-tbill
Rev. 1 /08 , a