410133_Well Construction - GW1_20130211

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NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2480
1. WELL CONTRACTOR:
Lewis LeFever
Well Contractor (Individual) Name
Parratt-Wolff, Inc.
Well Contractor Company Name
501 Millstone Drive
4i2;
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
Street Address = g. WATER ZONES (depth):
Hillsborough NC 27278 : Top N/A
City or Town State Zip Code
(919 ) 644-2814
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-105
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public D
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/24/12
4. WELL LOCATION:
Quality Drive
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Navassa CouNTY Brunswick
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 34 0 "DMS OR 34.25650703 DD
LONGITUDE 77 ' " DMS OR 77.98623561 DD
Latitude/longitude source: OOPS Vropographic 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.)
Former Estech General Cho
Facility Name
Quality Drive
Facility ID# (if applicable)
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'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO rif
c. WATER LEVEL Below Top of Casing: 0 FT.
(Use "+" if Above Top of Casing)
Top
Top
7. CASING: Depth ,
: Top 0 Bottom 15.0
Top
Top
8. GROUT:
: Top 0
Bottom
Bottom
Amount
Bottom Top
Bottom Top
Bottom Top
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
Ft. 1.5" Sch40 PVC
Ft.
Ft.
Depth Material
Bottom 10.0 Ft. Portland
Top 10.0 Bottom 13.0 Ft. Bentonite
Top Bottom Ft.
9. SCREEN: Depth
Top 15.0 Bottom 20.0
•
Diameter
Ft. 1.5 in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Method
Tremie
Tremie
Slot Size Material
.006 in. PVC
10. SAND/GRAVEL PACK:
Depth Size Material
Top 13.0 Bottom 20.0 Ft. #0 Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
/ No samples taken
12. REMARKS:
JL. L. 11 :t). 12'
r r°�' ce s s' i to,„,.
7 .r l
1 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 PROVIDE TO THE WELL OWNER.
• ...w... w ,,.wiuls Ae '" „ lI'+.art '" -1-1;.-.. j Y%
:4:-S9GNATUREcOF CERTIFIED WELL Lour ACTOVDAtrE41.
Lewis LeFever + F
PRINTED NAME OF PERSON CONST RUCtI9tIG tHE WELL
to
Form GW-1 b
Submit within 30 days of completion to: Division of Water Quality - Information Processing; Rev. 2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]

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