404303_Well Construction - GW1_20120416

NONRESIDENTIAL
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4110-.8
1. WELL CONTRACTOR:
Kirk McDonald
Well Contractor (Individual) Name
Practical Environmental Solutions
Well Contractor Company Name
P.O. Box 12590
Street Address
Wilmington
City or Town
(910 ) 790-8265
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# ACt
NC
State
OTHER ASSOCIATED PERMIT#(if applicable) 4dt
SITE WELL ID #(if applicable)
28405
Zip Code
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigationo Other ❑ (list use)
DATE DRILLED 3 `I6 ' I Z
4. WELL LOCATION:
2 0 2- Ro iCAa9 U Ir,k,
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: N'1 t t4j'\ COUNTY Prat.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley piiat ❑ Ridge ❑ Other
LATITUDE 34 ° 15 ' 6 203 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE ° F6 ' 1551 " DMS OR 7X.XXXXXXXXX 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.)
ILD C1 Ki is r 2o2
Facility Name' Facility ID# (if applicable)
2c72. Fto kottuiH1 lk 3 ct .
Street Address
LJG tic 4.6y, WC.. 24o9
C't or Town ' State Zip Code
keD144.4 !
Contact ame
!.5 (. iloilevbee Z..att e
Mailing 4ddress
(•,1)
City or Town v
() 9./2l39
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
wc
13.5
2t12
(Use "+" if Above Top of Casing)
State Zip Code
YES ❑ NO
FT.
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
404303
d. TOP OF CASING IS — O • 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): METHOD OF TEST'
: f. DISINFECTION: Type Amount
: g. WATER ZONES (depth):
: Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
: 7. CASING: Depth Diameter Weight
Top 0 • Bottom 3.5 Ft. 2 9c1i'C)
Top Bottom Ft.
: Top Bottom Ft.
: 8. GROUT: Depth Material
Top 0 Bottom 1 Ft.
: Top / Bottom -- Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter
: Top $ Bottom 13 -5- Ft. 2
Top Bottom Ft.
: Top Bottom Ft.
: 10. SAND/GRAVEL PACK:
. Depth Size
Top 2• 5 Bottom I? .$ Ft. 2
in.
in.
in.
: Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
• Top Bottom
0
u
�s
I
/
/
/
/
/
(I
L
2n
: 12. REMARKS:
Ccr•e..
Material
Q,(
Method
pc%) r-
be "oor
Slot Size Material
0 1 in. P‘re--
in.
in.
Material
of S�
rtazci_.
Formation DescriptiR
4it sc2.1
arm ci.%tc'''4'�.�
,b/oe ski 46a Ct4ey za,,d
I - 20 hc.Cole.5 t.ske 1l tQac `s
I DO HEREBY CERTIFY TH
: 15A N AC 2C, WEL
: RECOI 5.b1AS BE
THIS WELL WAS CO
RUCTION STANDARD
�E1dT THE WELl�I V1
N_/ACCORDANCE WITH
COPY OF THIS
S1GNA1 E OF CERTIFIE ELL CO TRACTOR•
•Al.t.4 Cye v1p id f i'
PRINTED NAME OF PERSON CONSTRUCTING THE WE4L
fl
1 i
Form GW-lb
Rew. 2I09
APR 1 6 2012