409003_Well Construction - GW1_20121113

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NON RESIDENTIAL WEt,t, CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9088 Northfield
Fort Mill S.C. 29707
City or Town State Zip Code
803 )_ 548-2180
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW- 9
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring 2P Municipal/Public D
Industrial/Commercial 0 Agricultural 0 Recovery D Injection I0
IrrigationD Other 0 (list use)
DATE DRILLED 10 - 9 -12
TIME COMPLETED 5: 00 AM 0' PM i
3. WELL LOCATION:
CITY: Wilmington COUNTY New Hanover
1608 Market Street 28401
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
C] Slope f i Valley ] Flat oRidge C3 Other
(check appropriate box)
LATITUDE 34.23731
LONGITUDE 77.92865
May be in degrees,
minutes. seconds or
in a decimal format
Latitudeflongitude source: GPS oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY. is the name of the business where the welt is loated.
FACILITY ID #(if applicable)
NAME OF FACILITY Modern Laundry
STREET ADDRESS 1608 Market Street
Wilmington N.C.
28401
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS Same
City or Town
t )-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 20
State Zip Code
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use ``+" if Above Top of Casing)
YES L NO
FT.
ic 0 '7' 0 0 3
d. TOP OF CASING 1S FT. Above Land Surface*
*Top of casing terminated atlor 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):
From To From To
From To From To
From To
From
6. CASING:
Depth Diameter
From 0 ' To 10 ' Ft. 2"
From To Ft.
From To Ft.
7. GROUT: Depth
From °' •To6'
Material
Ft. Portland
Thickness/
Weight Material
SCH 40 PVC
From To Ft.
From To Ft.
8. SCREEN: Depth
Diameter
Front 10' To 20' Ft.2" in.
From To Ft. in.
From To Ft. in.
9. SAND/GRAVEL PACK:
Depth Size
From 8 ' To 20 ' Ft. #2
From To Ft.
From
To Ft.
10. DRILLING LOG
From To
020' -
11. REMARKS:
Method
Trimmie
Slot Size Material
.010 in. PVC
in.
in,
Material
Sand
Formation Description
Sand
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I DO HEREBY CERTIFY T=, ' rHIS WELL WAS CONSTRUCTED,.!,ACCORDANCE WITH
15A NCAC 2C. WELL COt TRUC- ! _ ' TANDARDS. AND THi+ OPY OF THIS
RECORD HAS BEEN PROVIDED TO THE We . .
10-12-12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Randy Hoffman
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-lb
Rev. 7/05