403772_Well Construction - GW1_20120326

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1. WELL CONTRACTOR:
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3423
WILLIAM T. DUGG I NS
Well Contractor (Individual) Name
TERRACON CONSULTANTS, INC
Well Contractor Company Name
5240 GREEN'S DAIRY ROAD
Street Address
RALEIGH
City or Town
(919 ) 873-2 211
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
: d. TOP OF CASING IS 2 • 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); N/A METHOD OF TEST N/A
f, DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
NC 27605 : Top I' . Bottom Top Bottom
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) E I-2011-PZ-
3.WELL USE (Check One Box) Monitoring iMunicipal/Public C7
Industrial/Commercial Q Agricultural p Recovery p Injection
Irrigation❑ Other 0 (list use)
DATE DRILLED 12112/2012
• 4. WELL LOCATION: -
EAGLE ISLAND
(Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Op Code)
CITY: WILMINGTON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valiey LJFlat ❑Ridge C 'other cro00 10`4,
LATITUDE 36 ° DMS OR 4 . f ZD
LONGITUDE 75 ' " DMS OR ti DD
Latitude/longitude source: V3PS ❑Topographic map
(location of well must be shown on a USGS topo map andaltached to
this form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
7. CASING: Depth Diaret
Top t 2.1- Bottom' Ft.
: Top Bottom Ft.
: Top Bottom Ft.
Top Bottom Top Bottom
Top Bottom Top Bottom
: Thickness/
Weight Material
PVC-
: 8. GROUT: Depth
: Top Bottom 1Ft.
Top Bottom Ft.
Top Bottom Ft.
Material
PC(
Method
9. SCREEN: Depth Diameter Slot Size . Material
Top IS Bottom � r Ft. '2, in. n ,' in. P N/C.'
: Top Bottom . Ft. in.
COUNTY NEW HAN ;Top Bottom Ft. In.
C onfinert Disnns,9l facility NLA__
Facility Name Facility ID# (if applicable)
N/A
Street Address
FkG1FIS1AND
City or Town
&PI i-ct( C16,
Contact Nail �-
i li/jh 1/7
Mail g Adese
WI I _ MI N CFTC) N
City or Town
O z i 4k
Area code Phone number
6. WELL DETAILS: t
a. TOTAL DEPTH: rlo
NC
State Zip Code
Petve
NC ZS
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
c. WATER LEVEL Below Top of Casing: t '' FT.
(Use °+° if Above Top of Casing)
in.
in.
10. SAND/GRAVEL PACK:
Size Material
Depth
Z. aiN42
.
Top Bottom 35- Ft.
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
: Top Bottom
.
0 J ( l P
: I i z4
f 28.5
26.5 f ' 1. c
Formation Description
L-
ELT
9-1fria)
3t'S.3 cLikj
• t
1
/
12. REMARKS:
VAI\R 1 ejl
at‘gtoces,ia-uniti
Inform �W QICiOG
: 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 PROTO THE WELL OWNER.
3/12/12
: SIGNATLJ E OF CERTIFIED WELL CONTRACTOR DATE
•
• WILLI M T. D U GG I S
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Subunit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09