403771_Well Construction - GW1_20120326

4 r 7 F
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
*¢t n�,r ` -- — - WELL CONTRACTOR CERTIFICATION # 3423
1. WELL CONTRACTOR:
WILLIAM T. DUGGINS
Well Contractor (individual) Name
TERRACON CONSULTANTS, INC
Well Contractor Company Name
54O GREEN'S DAIRY ROAD
Street Address
RALEIGH
City or Town
(919 ) 873-2211
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 27605
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID Of applicable) E l-2011--PZ- j it
.3. WELL USE (Check One Box) Monitoring t iMunlcipal/Public D
Industrial/Commercial 0 Agricultural 0 Recovery 0 Infection D
IrrigationD Other 0 (list use)
DATE DRILLED 1J 52012
4. WELL LOCATION:
: d. TOP OF CASING IS Z - 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):
: Top 10 Bottom ic Top Bottom
Top Bottom Top Bottom,
Top , Bottom Top Bottom
. Thickness!
:7. CASING: Depth Diameter Weight Material
Top t le 1" Bottom kt , Ft. - T?VC
: Top Bottom Ft.
: Top Bottom Ft.
: 8. GROUT: Depth
Top (9 Bottom 33 Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
EAGLE ISLAND : Top
(Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Op Code) : Top
CITY: WILMINGTON COUNTY NEW HAND Top
TOPOGRAPHIC 1 LAND SETTING:
DSlope DValley DFlat D Ridge
LATITUDE 36
LONGITUDE 75 °
(check appropriate box)
'Other em 11014 krAtv5
"DMSOR31. 11,9t t 1 DD
" DMS OR `� G i_ . )t7 DD
Latitude/longitude source: VGPS Dtopographic map
(location of well must be shown on a USGS topo map andaftached to
this form if not using GPS)
5. FACILITY (Name of the business where the weft Is located.)
Confined Disnosal Facility NIA
Facility Name Facility ID# (if applicable)
N/A
Street Address
FAGI FIS1AND NO
City or Town State Zip Code
/,cCrr
ontact Name
kt:(r 1
!tiling Ad ress
WILMINGTON v7-6
NC
City or Town State
( q(o) l 464
Area code Phone umber
6. WELL DETAILS:
a. TOTAL DEPTH:
45�
b. DOES WELL REPLACE EXISTING WELL?
YES 0
Zip Code
NONO qI
c. WATER LEVEL Below Top of Casing: 0 FT.
(Use °*° If Above Top of Casing)
Top
Top
Top
11. DRILLING LOG
: Top Bottom
Diameter
35'901t0m45' , Ft. 2. in.
Bottom Ft. In.
Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth
Bottom 40
Slot Size
t9•l
Material Method
PC( 7re pi ,(
in.
in.
in.
Material
PV
Size Material
Ft. - No Z 5 it"Wl?
Bottom Ft.
Bottom Ft.
Formation Description
/ 54-t4
f .5-
: 3 5 5 / 5fl'0Q
42- c
SI
12. REMARKS:
RECE
MPS 1 9 201"4
• 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUC f grhl
: 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY (go
RECORD HAS $EEN PROVI Ti THE WELL OWNER.
SIGNA UR OF C' i ` IIED WELL CONTRACTOR DATE
Ir
3/12/12
WILLIAM T. DU GG1N�
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit 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