403774_Well Construction - GW1_20120326

NONRESI
North Carolina Department of E
1
1
MAR 2 6 2012
NTIAL WELL CONST UCTION RECORD
ne ed-Natufal-ResourYc-es..Division of Water Quality
0
WELL CONTRACTOR CERTIFICATION # 3423
't. WELL CONTRACTOR:
WILLIAM T. DUGGINS
Well Contractor (Indhii ia1J Name
TERRACON CONSULTANTS, INC
Well Contractor Company Name
5240 GREEN'S DAIRY ROAD
Street Address
RALEIGH
City or Town
(919 ) 873-2211
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NIA
NC, 27605
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) E I-201 1--PZ- 41Wr
3. WELL USE (Check One Box) Monitoring 11 Municipal/Public p
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
irrigation❑ Other 0 (list use)
DATE DRILLED 'IVIVZO1 Z
4. WELL LOCATION:
EAGLE ISLAND
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WILMINGTON COUNTY NEW FIANGtVgi Top
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope IValley iJFlat ClRidge Lather k Nh LchNK
LATITUDE 36 " DMS OR 3 1 . ! toci I DD
LONGITUDE 75 " DMS OR . s4eep
Latitude/longitude source: 3PS ❑Topographic map
(location of well must be shown on a USES topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.)
Confined Disnnsal Facility N/A
Facility Name Facility 1D# (if applicable)
N/A
Street Address
FACT I _F ISLAND
City or Town
e#i iA /c(rj
r
ontact Name r
9
ail ng Ad re
ew-ill/Do Pefrtue
WILMINGTON NC_ 2.6`
City or Town State Zip Code
( �{ io ) `L51 jtVict
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
A5'
NC
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES Q NO II
c. WATER LEVEL Below Top of Casing: 2t ) FT.
(Use d+° if Above Top of Casing)
: d. TOP OF CASING IS FT. Above Land Surface*
•
*Top of casing terminated at/or below land surface may require
a variancein accordance-with-15A-NCAC-2C:0118.
3-'1-
= e. YIELD (gpm): NIA METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top its - Bottom kc Bottom
Top Bottom Bottom
Top Bottom
Top
Top
Top
Bottom
Thickness/
7. CASING: Depth / Dlame -r Weight Material
Top I-2)-V' Bottom 45 Ft. 'ft
Top Bottom Ft.
Top Bottom Ft.
: 8. GROUT: Depth Material Method
: Top C0 Bottom 3 3 Ft. 1> C C
Top Bottom , Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top 31 " Bottom 4 Ft. In. 0 •1 in. pi(
: Top Bottom Ft. in. in.
Bottom Ft. in. in.
771"\<
10. SAND/GRAVEL PACK:
• DepthTop 3'' Bottom Ft_
Top Bottom FL
: Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
: 4-5
1
/
/
12. REMARKS:
Size Material
S`1`-r/
Formation Description
chNi2
t‘A-10
proCesst L1�
1fltala' QIBOC
• 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 PR El) TO THE WELL OWNER.
: SIG
3112/12
TURE O CFI-T1FIED WELL CONTRACTOR DATE
M T. DUGGINS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of cornpletion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09