HomeMy WebLinkAbout410440_Well Construction - GW1_20130211NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2973
1. WELL CONTRACTOR:
Kevin White
Well Contractor (Individual) Name
Parratt-Wolff, Inc.
Well Contractor Company Name
501 Millstone Drive
Street Address
Area code Phone number
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# : Top 0 Bottom 10.0 Ft. 2" Sch40 PVC
•
: 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
: g. WATER ZONES (depth):
Hillsborough NC 27278 : Top N/A Bottom Top Bottom
City or Town State Zip Code : Top Bottom Top Bottom
919 ) 644-2814 : Top Bottom Top Bottom
. Thickness/
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID #(if applicable) M W-106 : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection [yr
IrrigationD Other ❑ (list use)
DATE DRILLED 10/17/12
8. GROUT: Depth Material Method
Top 0 Bottom 6.0 Ft. Portland Tremie
Top 6.0 Bottom 8.0 Ft. Bentonite Tremie
Top Bottom Ft.
4. WELL LOCATION: : 9. SCREEN: Depth Diameter Slot Size Material
Quality Drive : Top 10.0 Bottom 20.0 Ft. 2 in. .006 in. PVC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) Top Bottom Ft. in. in.
CITY: Navassa COUNTY Brunswick Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
: 10. SAND/GRAVEL PACK:
34 ° "DMS OR 34.25650703 DD Depth Size Material
LATITUDE : Top 8.0 Bottom 20.0 Ft. #0 Sand
LONGITUDE 77 " DMS OR 77.98623561 DD i Top Bottom Ft.
Latitude/longitude source: ❑GPS Vropographic map i 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.) Top Bottom
•
Former Estech General Cher /
Facility Name Facility ID# (if applicable) : /
Quality Drive : /
Street Address : /
Navassa NC 28404 •/
City or Town State Zip Code
/
Contact Name •
Mailing Address :
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20.0'
12. REMARKS:
Formation Description
No samples taken
rF
7 t'
•
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 BEEPROVIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q(
SIG AN
c. WATER LEVEL Below Top of Casing: 1 1 .0
(Use "+" if Above Top of Casing)
FT.
URE OF CERTIFIED WELL CONTRACTQR
: Kevin White
PRINTED NAME OF PERSON CONSTRUCTING=T,_
Submit within 30 days of completion to: Division of Water Quality Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : (919) 807-6300
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