408507_Well Construction - GW1_20121022

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CON
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
•
OCT' 17 2012
CENTRAL FILES
DWCYBOG
NC 28428
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring Ci Municipal/Public 0
Industrial/Commercial 0 Agricultural ❑ Recovery ❑ Injection 0
irrigation❑ Other 0 (list use)
DATE DRILLED 9/5/20 1 2
4. WELL LOCATION:
708 Cape Fear Blvd. : Top 2 Bottom 12 Ft. 2 in. 0.01 in. pvc
Top
CITY: Wilmington COUNTY N.H.0 : Top
ION # 3470-A
n' 5114.7
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
7. CASING: Depth
Top 0
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
Diameter Weight
Bottom Ft. 2" Sch 4(
Top Bottom Ft.
Top Bottom Ft.
Material
PVC
8. GROUT: Depth Material Method
Top 0.5-1 Bottom Ft bentonite pour
Top 0-0.5 Bottom Ft. concrete pour
Top Bottom Ft.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley elat 0 Ridge ❑ Other
LATITUDE 34 ° 2 10.7900 "DMS OR 3X.xxXXXXXxx DD
LONGITUDE 77 54 • 16.4400 " DMS OR 7x.x:xxxx 000( 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.)
Cane Fear Blvd_ - 708 N/A
Facility Name Facility ID# (if applicable)
708 Cane Fear Blvd
Street Address
Carolina Beach
City or Town
Bill Henderson
Contact Name
1117 Military Cutoff Road
Mailing Address
Wilmington NC 28405
City or Town State Zip Code
( 910,16 509-3909
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES 0
NC 28428
State Zip Code
c. WATER LEVEL Below Top of Casing: 4.82
(Use "+" if Above Top of Casing)
NO q/
FT.
•
9. SCREEN: Depth Diameter Slot Size Material
Bottom
Bottom
Ft.
Ft.
: 10. SAND/GRAVEL PACK:
Depth
Top 1 Bottom
in. in.
in. in.
Size Material
12 , Ft. #2 torpedo sand
Top Bottom Ft. natural pack
Top
Bottom Ft.
: 11. DRILLING LOG
Top Bottom
0 /2
2 /4
4 /12
12. REMARKS:
Formation Description
Dark brown fine sand
Very light gray fine sand
orangish gray fine sand
Vljg
2 2 2612 k
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 =EEN PROVIDE. TO THE WELL OWNER.
•
SIGNATURE OF CERTIFIED WELL CO DATE
4w 9/5/12
William M. Wiggins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09