403722_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 Drillincti 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-7
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection Cd
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12-30-2011
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 38 Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 2 Bottom 36 Ft. 1" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 32- Bottom 35 Ft. Bentonite Chi pour
Top 0 Bottom 35 Ft. Grout
Top Bottom Ft.
4. WELL LOCATION: : 9. SCREEN: Depth
602 Sunnyvale Dr. 28412 : Top 36
Top
CITY: Wilminaton COUNTY NHC : Top
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Valley RfFlat ❑ Ridge ❑ Other
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
innnn��nnnnnnnl CI-ROR 34 4 63& A�� CC
KO STCD 34
IUNMFISTCD77 inn"n&nnnnnnnn! CL ROR ��!'�� `2J Ad I CC
Latitude/longitude source: V13PS ❑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 Packino and Cratino
Facility Name Facility ID# (if applicable)
602 Sunnyvale Drive
Street Address
Wilminoiton NC 28412
City or Town State Zip Code
Steve Tyler
Contact Name
804 Porters Neck Road
Mailing Address
Wilminafon NC 28411
City or Town State Zip Code
( 91 0 n 508-8833
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 40
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q/
c. WATER LEVEL Below Top of Casing: 5 FT.
(Use "+" if Above Top of Casing)
Diameter Slot Size Material
Bottom 38 Ft. 1
Bottom Ft.
Bottom Ft.
in. 0.01 in. PVC
in. in.
in. in.
: 10. SAND/GRAVEL PACK:
Depth Size
• Top 35 Bottom 38 Ft. #2
Top Bottom Ft.
: Top Bottom Ft.
. 11. DRILLING LOG
Top Bottom
•
•
•
Material
Torpedo
Formation Description
/ See attached
/
1
12. REMARKS:
v1A.R 1'5 2.012
•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECORDS BEEN P'OVIIED TO THE WELL OWNER.
j! f
SIGNA
E • CERTIFIEb WEL
: Bobbie Fowler
1-11-201
TOFF-- DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit within 30 days of :completion to: Division of Water Quail
17 Mari Service Center, Raleigh, NC 27699-161, Phone : [phone].
nformation Processing,
Form GW-lb
Rev. 1/08