408503_Well Construction - GW1_20121022

NONRESIDENTIAL WELL CONSTRUCTION RECORD
orth Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL COe`• TION # 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
OCT 17 2OZ
CTRALF6EEa
DWQIBOG
NC 28428
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-2
3. WELL USE (Check One Box) Monitoring Ni( Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationo Other ❑ (list use)
DATE DRILLED 9/5/2012
4. WELL LOCATION:
1624 Castle Havne Road
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY N.H.0
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
oSlope [Walley (Flat ❑ Ridge DOther
KCePSTCD 34 Aw'^ A P^ ^^ ^ I CL R OR 3kC^XXXC0C9490XX CC
KNMFISTCD 77 i^fa^Vaka '`^^I CL ROR NMeXXXIOOM CC
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.)
Castle Havne Road -1624 N/A
Facility Name Facility ID# (if applicable)
1624 Castle Havne Road
.rt o l et 0
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 Ft. 2" Sch 4( PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.5-1 Bottom Ft. bentonite
Top 0-0.5 Bottom Ft. concrete pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
: Top 2 Bottom 12
Top Bottom Ft. in.
Top Bottom Ft. in.
: 10. SAND/GRAVEL PACK:
Depth Size
Top 1 Bottom 12 Ft. #2
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
0 /2
•
• 4 /12
2 /4
Street Address :
Wilminalon NC 28401•
City or Town State Zip Code
Randy Burae
Contact Name
1117 Military Cutoff Road
Mailing Address
Wilminaton NC 28405
City or Town State Zip Code
( 910,E 509-3918
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ei
c. WATER LEVEL Below Top of Casing: 5.80
(Use "+" if Above Top of Casing)
FT.
/
/
/
/
12. REMARKS:
Method
pour
Material
Ft. 2 in. 0.01 in. pvc
in.
in.
Material
torpedo sand
natural pack
Formation Description
Dark brown clayey fine sand
Brown fine sand
Tan 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
RECORD HAS BEEN Pf20VIDED TO E WELL 01I NER.
f�
of
: SIGNATURE OF CERTIFIEb t/1JELL CONTRA
William M. Wigcjins
• PRINTED NAME OF PERSON CONSTRU
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
9/5/12
DATE