403712_Well Construction - GW1_20120315

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NONRESIDENTIAL WELL CONSTRUCTION RECORD . : 2
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2869
1. WELL CONTRACTOR:
Bobbie Fowler
Well Contractor (Individual) Name
Mid -Atlantic Drilling, Inc
Well Contractor Company Name
PO Box 315
Street Address
Carolina Beach
City or Town
(910 ) 458-5020
NC 28428
State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A - On- Site
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-SV3
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other [(list use) Soil Vapor Monitoring
DATE DRILLED 12-28-2011
4. WELL LOCATION:
602 Sunnyvale Dr. 28412
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
d. TOP OF CASING IS 0 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 5 Bottom 7 Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 2 Ft. 2" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
▪ Top .5 Bottom 1 Ft. Bentonite Chi pour
Top 0 Bottom .5 Ft. Grout
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 2 Bottom 7 Ft. 2 in. 0.01 in. PVC
Top Bottom Ft. in. in.
CITY: Wilmington COUNTY NHC : Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley elat ❑ Ridge ❑Other
Ktf$TCD 34 ^^^^$iAAAAAAAA I CL R OR 34"1M^^^^^ CC
KNMF l$TCD 77 i AAAA&AAAAAAAA! CL R OR 7l7 n34'AAAAA CC
Latitude/longitude source: (BPS ❑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.)
S&R Packina and Crating
Facility Name Facility ID# (if applicable)
602 Sunnyvale Drive
Street Address
Wilminaton NC 28412
City or Town State Zip Code
Steve Tyler
Contact Name
804 Porters Neck Road
Mailing Address
Wilminaton NC 28411
City or Town State Zip Code
( 910 , 508-8833
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 7'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO q/
c. WATER LEVEL Below Top of Casing: 5 FT.
(Use "+" if Above Top of Casing)
: 10. SAND/GRAVEL PACK:
•
Depth Size Material
Top 1 Bottom 7 Ft. #2 torpedo
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
•
/ See attached
12. REMARKS:
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.
1-11-201
SIGNATURE OF CRTIFI WELL C • NTRACTOR DATE
: Bobbie Fowler
•
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality
1617 Mail Service Center, Raleigh, NC 27699-161, :Phone : [phone]
Form GW-lb
Rev. 1/08