403757_Well Construction - GW1_20120319

CEVE
, MAR 2s06�20�Z� a
Caro
1. WELL COr'I ACTOR:
Kirk McDonald
nc'`,c '^i
RESIDENTIAL WELL CONSTRUCTION RECO
ar(ment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4110-B
Well Contractor (Individual) Name
Practical Environmental Solutions
VVe11-C-ontractor Company Name
P.O. Box 12590
Street Address
Wilmington NC 28405
City or Town State Zip Code
(910 ) 790-8265
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
Act
OTHER ASSOCIATED PERMIT#(ifi ap iicable) 4+a
SITE WELL ID # if
applicable)
W—I
3. WELL USE (Check One Box) Monitoring Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other ❑ ffist use)
DATE DRILLED 3 -IS- 12
4. WELL LOCATION:
270-'1- ci; e r�wc..
(Street Name, Numbers, Community Subdivision, Lot No., Parcel, Zip Code).
CITY: 4 O I 46A- COUNTY (4&4) aomar
.
TOPOGRAPHIC LAND SE 1 1 ING: (check appropriate L box)
❑Slope ❑ Valley L3'Flat ❑ Ridge ❑Other
LATITUDE 3�{ ° 22 ' 2V I " DMS OR 3X.XXXXXXXxx DD
LONGITUDE ag 22 ° ' ?16 "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.)
CsawLr:dsh)
Facility Nam"
Facility ID# (if applicable)
2%.).4 C4461. 111.12;
Sr t et ddress
City or Town
Lte 14,4
N C 2.€1-O3
State Zip Code
Contact Name
270 7 c:J
Mailing iAddress
Ck.) 1 �I hit t i1- S" 'y, ...,
City or Town J
r/O ) 2-G � - 2368
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
IBC 2 &403
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: f l
(Use "+" if Above Top of Casing)
NO
FT.
d. TOP OF CASING IS o 0. 3 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 (9Pm): METHOD OF TEST'........_._
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
: Top Bottom
Top Bottom
Top Bottom
7. CASING: Depth Diameter
2.
Top 0 Bottom Ft. .
Top Bottom
Top • Bottom
Top • Bottom
Thickness/
Weight Material
Scit PVC -
Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth Material
Top0 Bottom I Ft. < d - r'�
,5
: Top I Bottom . Ft.
Top Bottom Ft.
Method
Poe'
krem.‘16,7,t`te
9. SCREEN: Depth
: Top Bottom . j - Ft. 2 in. 0,0 t
Top Bottom Ft. in.
: Top Bottom Ft. in.
: 10. SAND/GRAVEL PACK:
T: , Depth l
TopBottom 0
: Top
Top
Bottom
Bottom
11. DRILLING LOG
Top Bottom
1.5 / .o
q.o / 1 0
/
: 12. REMARKS:
Size
Ft.
Ft.
Ft.
Diameter Slot Size - Material
PK-
•
in.
in.
in.
Materia
Formation D\4\1\ 01‘it
escription �cocess
(l,jj,QG
'Pi) &bun"- e_ efel. 5ariel r kt,
Sec ker
I DO H
:15AN
: RECOR
EBY C RTI THAT THIS W
C 2C, 1 E ONSTRUCT
PROS-_.
STRUCTED IN ACCORDANCE WITH
oS, AND THAT A COPY OF THIS
WNER.
SIGtdATi RE OF CERTIF���Q �� ONTRACTOR
Acc
3/-17—.
DATE
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. 2109