411704_Well Construction - GW1_20130208

1. WELL CONTRACTOR:
Kelly Grant
NON RESIDENTIAL WELL CONSTRUCTION RECORD
4/ 01
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North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2730-A
Well Contractor (Individual) Name
American Environmental Drilling, Inc.
Well Contractor Company Name
324 Fields Drive Suite C
Slreel Address
Aherdeen NC 28315
City or Town State Zip Code
L910__1.- 944-3140
Area mrle- Ftrna rurber
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT #
OTHER ASSOCIATED PERMIT Cif applicable)
SITE WELL ID Cif applicable) MW-5
3. WELL USE (Check Applicable Box) Monitoring ® Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
Irrigation 0 Other 0 (list use)
DATE DRILLED 12-28-12
4. WELL LOCATION:
3498 OLD WILMINGTON HWY
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Zip Code)
CITY. VERONA COUNTY ONSLOW
TOPOGRAPHIC / LAND SETTING: (check appropriate box).
❑Slope 0Valley ®Flat ❑Ridge DOther
LATITUDE 34° 39" 20.37" " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77° 29" 55.58" "DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source ®G PS ❑ Topographic map (location of
well must be shown on a USGS top map and attached 10 this form
if not using GPS)
5. FACILITY- is the name of the business where the well is located.
VERONA QUICK MART
Facility Name Facility ID #(if applicable)
3498 OLD WILMINGTON HWY
Street Address
VERONA no
City or Town State
SCOTT DRISCOLL(E.J.POPE
Contacl Name
P.O. DRAWER 649
28365
Zip Code
Mailing Address
MT.OLIVE NC 28365
City or Town
f 1
Slate Zip Code
Area code - Phone number
6. WELL DETAILS:
:r. 12
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing:2.4 FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS -.6 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) METHOD OF TEST
f DISINFECTION: Type Amount
0
WATER ZONES (depth);
Top 2.4 Bottom 12 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top D Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
2 Ft.2 SCH40 PVC
Ft.
Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 6" Ft. NEAT CEMENT POUR
Top 6" Bottom 1 Ft BENTONITE POUR
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
Top 2 Bottom 12 Ft.2 in..010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 1 Bottom
Top Bottom
Top Bottom
11. DRILLING LOG:
Top Bottom
0 /2
2 /3
3 /12
12. REMARKS;
Size Material
12 Ft #3 SAND
Ft
Ft
Formation Description
BROWN SAND
BLACK SANDY CLAY
GRAY SANDY CLAY
RECEV
FEB d 8 209?
Ytii4UPt°t➢afiio11ProcS%Stag ltr;t
DWQ/BOG
Ft& 13t-7a93
I DO HEREBY CERTIFY THAT THISWEhtrWAS-CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. ANI) THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELLOWNER
-(^OtiL1 fr^' 12-28-12
SIGNATURE OF C)iiTIFIED WELL CONTRACTOR
Kelly Grant
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to the Division of Water Quality - Information Processing,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone]
DATE
Form GW-1b
Rev. 2/09