400609_Well Construction - GW1_20120109

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # NCWC 3094-A
1. WELL CONTRACTOR:
Ronald E Stewart
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
NC 28428
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-1
d. TOP OF CASING IS -0.25 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
-a variance in -accordance with 15A NCAC 2C .011.8.
•
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 4 Ft. -2 sch40 PVC
: Top Bottom Ft.
Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑ : 8. GROUT: Depth Material Method
Industrial/Commercial ❑ Agricultural 0 .Recovery 0 -Injection.❑ : Top 0 Bottom 1 Ft. cement pour
Irrigationo Other 0 (list use) : Top 1 Bottom 2 Ft bentonite pour
DATE DRILLED 12/21 /201 1 : Top Bottom Ft.
4. WELL LOCATION: 9. SCREEN: Depth Diameter Slot Size Material
3810 Edaewood Road : Top 4 Bottom 14 Ft. 2 in. 0.01 in. PVC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
34 21 385.0000 Depth Size Material
LATITUDEDMS OR 3x.xxxxxxxxx DD Top .2 Bottom 4 Ft. #2 torpedo
LONGITUDE 77 ° 90 , 4,450.0000 DMS OR 7X.xxxxx xxx DD :Top Bottom Ft.
Latitude/longitude source: ❑GPS :Topographic map : Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) : 11. DRILLING LOG
5. FACILITY (Name of the business where the well is located.) i Top Bottom
Edaewood Road - 3810 : 0 / 7 all
Facility Name Facility ID# (if applicable) 7 / 8
3810 Edaewood Road : 8 / 10
: Top Bottom Ft. in. in.
CITY: Wiiminaton COUNTY NHC : Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box) .
❑ Slope ❑Valley hifFlat ❑ Ridge ❑Other : 10. SAND/GRAVEL PACK:
Street Address 10 / 14
Wilmington NC /
City or Town State Zip Code : /
David Padgett • /
Contact Name /
3810 Edaewood Road
Mailing Address
Wilminaton
NC
City or Town State Zip Code
( 910, 470-4861
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 14
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [if
c. WATER LEVEL Below Top of Casing: 6 FT.
(Use "+" if Above Top of Casing)
Formation Description
gray sandy clay
brown clayey silt
white fine sand
/ r
12. REMARKS:
2flj77
DwQ/B0Gocessif
• 1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
. 15A NCAC 2C, WELL CONSTRUCTION,STANDA. • �, AND THAT A COPY -OF THIS
RECORD HAS BEEN PROVIDED TO THE OWNER:
SIG ATURE OF CERTIFIED �'`�SNTRACOR
: Ronald E Stewart
PRINTED NAME OF PERSON CONSTRUCTING TH
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form OW-1 b
Rev. 2/09