409733_Well Construction - GW1_20121210

•
'ice
1. WELL CONTRACTOR:
William M Wiggins
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3470-A
Well Contractor (Individual) Name
Mid -Atlantic Drilling Inc.
Well Contractor Company Name
PO Box315
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) N/A
SITE WELL ID #(if applicable) MW-1
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation0 Other ❑ (list use)
DATE DRILLED 10/12/2012
4. WELL LOCATION:
1002 N. 3rd Street
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
C.TY: Wilmington COUNTY N.H.0
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Valley elat ❑ Ridge DOther
K(l-$T CD 34 `A14A ^ 80661:"^^ ^ I CL R OR 3x^)EXXXX Xxx CC
KNMF i-STCD 77 i ^sa^8tM0O`AA! CL R OR 7 'y000100' 0N' CC
Latitude/longitude source: ❑3PS 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.)
Liahthouse Tract 1 N/A
• Facility Name Facility ID# (if applicable)
1002 N. 3rd Street
Street Address
Wilminaton NC 28401
City or Town State Zip Code
Bill Henderson
Contact Name
1117 Military Cutoff Road
Mailing Address
Wilminaton NC 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 0
c. WATER LEVEL Below Top of Casing: 18.64
(Use "+" if Above Top of Casing)
NO q%
FT.
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
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 14 Ft. 2" Sch 4C PVC
: 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.
9. SCREEN: Depth Diameter Slot Size Material
: Top 14 Bottom 24 Ft. 2 in. 0.01 in. pvc
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top 12 Bottom 24
Bottom
Bottom
Size Material
Ft. #2 torpedo sand
Ft. natural pack
Ft.
Formation Description
0 / 6 Brown and orange medium sand
6 / 18 Tan and gray medium sand
• ▪ 18 / 24 Brown and gray medium sand
/
/
•
Top
: Top
: 11. DRILLING LOG
Top Bottom
12. REMARKS:
‚E:C
NO\? g zov,
: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
. 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REQQRD�HA� B TROVIDED T WELL 9 )N R.
SIGI3ATURE OF CERTIFIED WELL CONTRA
1240/23/12
DATE
E,tr
DEC
HE-1
0 2012
orm GW-1 b
Rev. 1/08
PRINTED NAME OF PERSON CONSTRUCTI,
Submit within 30 days of completion to: Division of Water Quality Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]