403717_Well Construction - GW1_20120315

NONRESIDENTIAL WELL CONSTRUCTION RECORD
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 Drillina, 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) PAS-2
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection G '
Irrigation❑ Other ❑ (list use)
DATE DRILLED 1-4-2012
4. WELL LOCATION:
602 Sunnyvale Dr. 28412
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY NHC : Top Bottom Ft. in. in.
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):
Top 5 Bottom 39 Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 37 Ft. 1" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
: Top 33 Bottom 36 Ft. Bentonite Chi pour
Top 0 Bottom 33 Ft. Grout
Top Bottom Ft.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley elat ❑Ridge ❑Other
K@SF$TCD 34 iAAAA&AAAAAAAAI CL R OR 34 4?63AAAAA CC
KNMF F$TCD 77. i AAAAVAAAAAAA I CL R OR 77!93408AAAA CC
Latitude/longitude source: 3PS ❑Topographic rnap
(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
602 Sunnyvale Drive
Street Address
Wilnnoton
City or Town
Steve Tyler
Contact Name
804 Porters Neck Road
Mailing Address
Wilminaton NC 28411 •
City or Town State Zip Code
( 910ni 508-8833
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 39'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
c. WATER LEVEL Below Top of Casing: 5
(Use "+" if Above Top of Casing)
Facility ID# (if applicable)
NC 28412
State Zip Code
FT.
•
9. SCREEN: Depth Diameter Slot Size Material
Top 37 Bottom 39 Ft. 1 in. 0.01 in. PVC
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
• Depth Size Material
Top 36 Bottom 39 Ft. #2 Torpedo
Top Bottom Ft.
Top Bottom FL
: 11. DRILLING LOG
• Top Bottom Formation Description
/ See attached
/
/
12. REMARKS:
MA[ 15 ZOIZ
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.
SIGNATUR O CERTIFIED 1�V -- 1-1 1-201
ELL CONTRACTOR DATE
Bobbie Fowler
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
Submit within 30 days of completion to: Division of Water Qual�_
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone],
Form GW-1 b
Rev. 1/08