404629_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 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: : 7. CASING: Depth
WELL CONSTRUCTION PERMIT# ; Top +0.5 Bottom -0.5
NC 28428
Stater: Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-B3
3. WELL USE (Check One Box) Monitoring W. Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 3/14/20 1 2
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 0 Flat i1 Ridge 0 Other
KKI$TCD 34 iAAAA&AAAAAAAA! CL R OR 34446527 CC
KNMF F$TCD 77 iAAAA&AAAAAAAA! CL R OR 77!95O8952 cc
Latitude/longitude source: 3PS QTopographic 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.
Street Address
WiIminaton
City or Town
Adam Lisk
Contact Name
720 North ThirdSlre_etSte 202
Mailing Address
Wilminaton
City or Town
( 910 JE 251-6160
Facility ID# (if applicable)
NC 28401
State Zip Code
NC
State
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 44"
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 3.5
(Use "+" if Above Top of Casing)
28401
Zip Code
NO q/
FT.
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/
Diameter Weight Material
Ft. 2" S 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
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. in.
: Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top -0.25 Bottom -3.75 Ft.
Top Bottom Ft.
: Top Bottom Ft.
'fl r-‘) L', [Pi
Size Material
''j: i' i APR 2 3 2012
I
1
: 11. DRILLING LOG
Top Bottom Formation Description
0 / -4 Disturbed Sediment and Debris
12. REMARKS:
\JED
APR 1 71112
information ration Processing Unit
ovva/B
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.
• dE. 5 3/26/20
• SIGNATURE OF CERTIFIED WELL— 1
CONTRACTOR DATE
: Ronald E Stewart
•
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit within 30 days of completIP II II
ion to: Division of Water Quai
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
Form GW-1 b
Rev. 1/08