409730_Well Construction - GW1_20121210

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2869.A
1. WELL CONTRACTOR:
Bobbie Fowler
Well Contractor (Individual) Name
Mid -Atlantic Drilling Inc.
Well Contractor Company Name
PO Box 315.
Street Address
Carolina Beach
NC 28428
City or Town State Zip Code
(910 ) 458-5020
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-I
3. WELL USE (Check One Box) Monitoring t Municipal/Public D
Industrial/Commercial D Agricultural 0 Recovery 0 Injection 0
Irrigation[ Other 0 (list use)
DATE DRILLED 10-26-12
4. WELL LOCATION:
Willanda Drive 215
(Street Name, Numbers; Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY N.H.0
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Ci Slope o VelleY iinat ❑ Ridge L j Other
K F$T CD 34 i' A 8 1 CL R OR 3X'-')00CXXXXXX CC
KNMFISTCD77 iAge& ,65*-8 l CL R OR MX oC CC
Latitude/Iongitude source: D3PS Qropographic map
(location of well must be shown on a USES topo map andattached to
this form if not using GPS)
d. TOP 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 15 Ft. 21 Sch 4C PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 9 Bottom 13 Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth.
Top 15 Bottom 25
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Method
Diameter Slot Size Material
Ft. 2 in. 0.01 in. PVC
Ft. in. in.
Ft. in. in.
Depth Size Material
Top 13 Bottom 25 Ft. 2 Torpedo Sand
Top i Bottom 9 Ft. Natural Pack
Top Bottom Ft.
: 11. DRILLING LOG
5. FACILITY (Name of the business where the well is located.) Top Bottom
0 /.12
Facility ID# (if applicable) 12 / 13.5
215 Willanda Drive 13.5 / 25
Willanda Drive - 215 N/A
Facility Name
Street Address
/
Wiimincfon NC /
City or Town State Zip Code /
Lin d a Stewart
Contact Name
115 Cams Court
Mailing Address
Wllminattn NC 28409
City or Town State Zip Code
( 910 791-2044
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 54
c. WATER LEVEL Below Top of Casing: 16 FT.
(Use 1i+" if Above Top of Casing)
/
/
/
12. REMARKS:
Formation Description
._.Fill Sand
Light gray sandy clay
Light brown to White Fine Sand
•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL .CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS, d
. RECORD HAS BEEN PRO IDE P TO THE WEL • INNER.
SIGH C
ELL CONTRACTOR
: ▪ Bobbie Fowler
PRINTED NAME OF PERSON CONSTRUCTIN' ° Q'
Submit within 30 days of completion to Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
DEIe