403721_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 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- Air
SITE WELL ID #(if applicable) PAS-6
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection Fir
Irrigation❑ Other 0 (list use)
DATE DRILLED 1-3-2012
4. WELL LOCATION:
602 Sunnyvale Dr. 28412
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY NHC
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley grFlat ❑Ridge ❑ Other
KKISTCD 34 iAAAA&AAAAAAAAI CL ROR 34;t47,648&AiA CC
KNMI= FSTCD 77 i ^^^^&^^^^^A^A! CL R OR 777^934'427^^^ CC
Latitude/longitude source: WXPS :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 Cratina
Facility Name Facility ID# (if applicable)
602 Sunnyvale Drive
Street Address
Wilmington NC 28412
City or Town State Zip Code
Steve Tvler
Contact Name
804 Porters Neck Road
Mailing Address
Wilmington NC 28411
City or Town State Zip Code
( 910 n 508-8833
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 40
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO cj
c. WATER LEVEL Below Top of Casing: 5
(Use "+" if Above Top of Casing)
FT.
•
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
g. WATER ZONES (depth):
Top 5 Bottom 40
: Top Bottom
Top Bottom
7. CASING: Depth
Amount N/A
Top Bottom
Top Bottom
Top Bottom
Diameter
Top 0 Bottom 38 Ft. I"
: Top Bottom Ft.
Bottom Ft.
Top
Thickness/
Weight Material
sch40 PVC
8. GROUT: Depth Material
Top 34- Bottom 37 Ft. Bentonite Chi
Top 0 Bottom 34 Ft. Grout
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
: Top 38 Bottom 40 Ft. 1 in.
Top Bottom Ft. in.
Top Bottom Ft. in.
: 10. SAND/GRAVEL PACK:
Depth Size
•
Top 37 Bottom 40 Ft. #2
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
•
•
Method
pour
Material
0.01 in. PVC
in.
in.
Material
Torpedo
Formation Description
/ See attached
/
12. REMARKS:
MAR . 2u17
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.
.
t-11-201
SIGNA r E . CERFI 1 LL �' CTOR DATE
: Bobbie Fowler
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processin
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 1/08