409732_Well Construction - GW1_20121210

Facility Name
1002 N. 3rd Street
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 Drilling 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) N/A
SITE WELL ID #(if applicable) MW-3
3. WELL USE (Check One Box) Monitoring d Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 10/12/2012
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, 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 Bottom
Top Bottom Top Bottom
Top Bottom Top 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.
CITY: Wilmington COUNTY N.H.0 : Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other
LATITUDE 34 ° 14 f 48.5000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 56 , 49.3000 " DMS OR 7X.XX000000X DD
Latitude/longitude source: ❑GPS ❑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.)
: 10. SAND/GRAVEL PACK:
Depth
Top 12
Size Material
Bottom 24 Ft. #2 torpedo sand
Top Bottom
: Top Bottom
: 11. DRILLING LOG
Top
Lighthouse Tract 1 N/A : 0 / 6
Facility ID# (if applicable) • 6 / 18
18 / 24
Street Address /
Wilminaton NC 28401 /
City or Town State Zip Code /
Bill Henderson
Contact Name
1117 MilitarvCutoff Road
Mailing Address
/
/
Wilminolon NC 28405
City or Town State Zip Code
( 910JE 309-3909
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 24
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
c. WATER LEVEL Below Top of Casing: 18.44
(Use "+" if Above Top of Casing)
FT.
12. REMARKS:
Ft. natural pack
Ft.
Bottom Formation Description
Brown and orange medium sand
Tan and gray medium sand
Brown and gray medium sand
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149,
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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 BEEN PROVIDED TWELL OWNER.
"Tiviiu.
SIGNATURE 0
CERTIFI
D WELL CQQ,N
William M. Wiggins
. PRINTED NAME OF PERSON CONS
Submit within 30 days of :completion .to: Division of Water Quality
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
10/23/12
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Form GW-1 b
information Processing,