403766_Well Construction - GW1_20120326

1. WELL CONTRACTOR:
WILLIAM T. DUGGINS
Weft-C-ontreetor-(individual)-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# N/A
NC
State
27605
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(ir applicable) E1-201 1 -PZ- �p
3. WELL USE (Check One Box) Monitoring liMunicipallPublic 0
Industrial/Commercial ❑ Agricultural D Recovery 0 Injection ❑
Irrigationo Other a (list use) • -
DATE DRILLED 1 dtI2012
4. WELL LOCATION:
EAGLE ISLAND
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Ziip Code)
CITY: WILMINGTON COUNTYNEW HANCIN
TOPOGRAPHIC / LAND SETTING: (check appro riate box)
Q
❑SlaP a Valle FlaRidiler 17114 � 4 I
y Ot p 9e �tdd
LATITUDE 36 "DMS OR 3T. zoos) , DD
LONGITUDE 75 "DMS OR p, /4 B DD
Latitud.e/longitude source: liZGPS [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.)
Confined Disnosal Facility N/A
Facility Name Facility ID# (if applicable)
N/A
Street Address
EAGLF ISI AND
City or Town
C `r
?ctNapj.e
ail gAds
WILMINGTON 2.6
City or Town Stale Zip Code
�)IS- 4Ltkt
Are code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH:
NC
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Cyr
c. WATER LEVEL Below Top g of Casing: Ilk' 2) FT.
(Use °+° if Above Top of Casing)
., ESIDENTIAL WELL CONSTRUCTION RECORD
North Carina epartment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3423
: d. TOP OF CASING IS 2- FT. Above Land Surface`
*Top of casing terminated at/or below land surface may require
-: - - -a-ariance-In-accordance-with-15A- NCAC -2-C-.O118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: *Wpe NIA Amount N/A
g. WATER ZONES (depth):
Top I il- 6 Bottom 3 c Top Bottom
Top Bottom Top Bottom
Top Bottom . Top Bottom
7. CASING: Depth
Top if' 2•' Bottom 35 Ft.
Top Bottom Ft.
: Top • Bottom Ft.
Thickness/
Diam . er Weight Material
pvc.
: 8. GROUT: Depth
Top 0 Bottom 1.5
ii Top Bottom Ft.
Top , Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
• 1 evc
;Top 75-Bottom Ts- � Ft. —�. in. 0. , in: .
Top Bottom Ft. in. in.
M.: Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
. Depth Size Material
Top Bottom 3-5— Ft. # 2_ 5ft4"D
Material
Ft. 'C.- C
Method
T,'ekl ,
Top ,Bottom Ft.
: Top Bottom Ft.
11. DRILLING LOG
: Top Bottom Formation Description
2Q'4
1
:
/
:_
12. REMARKS:
sin
S t 1-T
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 PROVIDED TO THE WELL OWNER.
3/12/12
SIGN ftIRO C ' � 1 D WELL CONTRACTOR DATE
WILIAI T, DUGGLNS
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