404636_Well Construction - GW1_20120423

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3094-A
1. WELL CONTRACTOR:
Ronald E Stewart
Well Contractor (Individual) Name
Mid -Atlantic Drillina, 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#
NC
State
28428
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-A1
3. WELL USE (Check One Box) Monitoring at Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 3/13/2012
4. WELL LOCATION:
Proposed Wilminaton River Front Marina
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Han
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley ❑ Flat 1A6 Ridge ❑ Other
LATITUDE 34 " DMS OR 34.24769238 DD
LONGITUDE 77 " DMS OR 77.95153503 DD
Latitude/longitude source: 3PS ❑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.)
River Front Marina
Facility Name
Nutt St_
Facility ID# (if applicable)
Street Address
Wilminaton
City or Town
Adam Link
NC
State
28401
Zip Code
Contact Name
720 North Third Street Ste_ 202
Mailing Address
Wilmington NC 28401
City or Town State Zip Code
( 910,a 251-6160
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 78"
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO q/
c. WATER LEVEL Below Top of Casing: —5
(Use "+" if Above Top of Casing)
FT.
4 F.3 3
d. TOP OF CASING IS 1.5 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): NA METHOD OF TEST NA
f. DISINFECTION: Type NA
Amount NA
: g. WATER ZONES (depth):
Top -5 Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top +1.5 Bottom -0.5 Ft. 2" S 40 PVC
: Top Bottom Ft.
Top Bottom Ft.
•
8. GROUT: Depth
Top 0 Bottom -0.25 Ft.
Top Bottom Ft.
Top Bottom Ft.
Material Method
9. SCREEN: Depth Diameter Slot Size Material
Top -0.5 Bottom -6.5 Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top -0.25 Bottom -6.5 Ft.
Top Bottom Ft.
: Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Top Bottom Ft. in.
11 II
Formation Description
0 / -6.5 Disturbed Sediment and Debris
/
/
12. REMARKS:
•
IVED
PR I 2012
qnfors �.' 1i
n Pra����''ppl1cessin-g Unit
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED iNCCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d 3/26/201
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Ronald E Stewart
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit within 30 days of completion to: Division of Water Quail'
1617 Mail Service Center. Raleigh. NC 27699-161. Phone : 19191 Rn7-annn
Information Processin
Form GW-1 b
Rev. 2/09