404631_Well Construction - GW1_20120423

NONRESIDENTIAL WELL CONSTRUCTION RECORD
iDepartment Environment andNatural Resources- Divi ion of Water Quality,- 0 4
North Carolina of Env ronmes Q tyL ..._ .�,3 I
WELL CONTRACTOR CERTIFICATION # 3094-A
1. WELL CONTRACTOR:
Ronald E Stewart
Well Contractor (Individual) Name
Mid -Atlantic Drillings 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#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-C2
3. WELL USE (Check One Box) Monitoring Ei Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 3/13/2012
NC
State
28428
Zip Code
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 ❑ FlatI Ridge DOther
KcF$TCD 34 iAAAA&AAAAAAAA! CL R OR 34i)2188&14A CC
1 NMF 1ST CD 77 jAAAA&AAAAAAAA! CL R OR 77151'3901e cc
Latitude/longitude source: VGPS :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
Wilmington NC 28401
City or Town State Zip Code
Adarn Lisk
Contact Name
720 North Third Street Ste. 202
Mailing Address
Wilmington
City or Town
c 910i6 251-6160
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 44"
d. TOP OF CASING IS 0.5 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 Bottom Top Bottom
: Top Bottom Top Bottom
: Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top +0.5 Bottom -0.5 Ft. 2" S 40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
i Top 0 Bottom -0.25 Ft.
: Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top -0.5 Bottom -3.75 Ft. in. in.
Top Bottom • Ft. in. ritr . F-
f IL-,'"' L '2) 1 L , I 1
: Top Bottom Ft. in. i in.
G 0
: 10. SAND/GRAVEL PACK: , ;1 ; APR 2 3 2012
J4
• Depth Size Nigeria/•
Top -0.25 Bottom -3.75 Ft.
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
• Top Bottom Formation Description
•
0 / -4 Disturbed Sediment and Debris
•
•
•
NC 28401
State Zip Code 12. REMARKS:
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO q/
c. WATER LEVEL Below Top of Casing: 3.25
(Use "+" if Above Top of Casing)
FT.
RECEIVEO
APR z012
InformAtio "I oroct.ssing'
DWQ18o
• 1 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 PROVIDED TO THE WELL OWNER.
21-meti, 5,ege4 ,,a 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 Quali
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 1/08