403719_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 Foweler
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
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A - On- Site
NC 28428
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A- Ambient Air
SITE WELL ID #(if applicable) PAS-4
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection Nor
Irrigation❑ Other ❑ (list use)
DATE DRILLED 1-5-2012
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 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
i g. WATER ZONES (depth):
Top 5 Bottom 34 Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 32 Ft. 1 " sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
,
8. GROUT: Depth Material Method
Top 2g- Bottom 31 Ft. Bentonite Chi pour
Top 0 Bottom 28 Ft. Grout
Top Bottom Ft.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley iifFlat ❑ Ridge ❑Other
Kcg1$TCD 34 i AAAA&AAAAAAAAl CL R OR 34A476/AAAAA CC
KNMF F$TCD 77 i AAAA&AAAAAAAA! CL R OR 77f934ichAAAAA CC
Latitude/longitude source: 3PS ❑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 Packi_na.and Cratina
Facility Name Facility ID# (if applicable) ;
602 Sunnyvale Drive •
: 9. SCREEN: Depth Diameter Slot Size Material
Top 32 Bottom 34 Ft. 1 in. 0.01 in. PVC
Top Bottom Ft. in. in.
Street Address •
Wilminat n NC 28412
City or Town State Zip Code
Steve Tyler•
Contact Name
804 Porters Neck Road
Mailing Address
Wilmington NC 28411
City or Town State Zip Code
( 910,E 508-8833
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 34
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
c. WATER LEVEL Below Top of Casing: 5 FT.
(Use "+" if Above Top of Casing)
•
: 10. SAND/GRAVEL PACK:
• Depth Size
Top 31 Bottom 34 Ft. #2
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
•
/
1
12. REMARKS:
Material
Torpedo
Formation Description
See attached
rfr
`Ef 1;L
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 BE P - • VIDED TO THE WELL OWNER.
CbAk re
SIGNA - E • C TIFIED E L CONTR
Bobbie Fowler
1-11-201
TOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quail
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,:
Form GW-1 b
Rev. 1/08