405531_Well Construction - GW1_20120606

1. WELL CONTRACTOR:
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2616-A
JIMMY S QUINN
Well Contractor (Individual) Name
QUINNS WELL DRILLING
Well Contractor Company Name
3242 POTTERS HILL RD
Street Address
PINK HILL
City or Town
(252 ) 568-2380
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 24681
NC
State
28572
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
lrrigation(1 Other ❑ (list use)
DATE DRILLED 9-23-11
4. WELL LOCATION:
WARDS BRIDGE RD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: KENANSVILLE couNTY DUPLIN
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Valley 'Flat ❑ Ridge ❑Other
LATITUDE I)24743 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE `« ° " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: PS ❑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.)
GRAPE VINES
Facility Name
WARDS BRIDGE RD
Street Address
KENANSVILLE
City or Town
DENNIS STROUD
Contact Name
PO BOX 726
Facility ID# (if applicable)
NC 28349
State Zip Code
Mailing Address
KENANSVILLE NC 28349
City or Town State Zip ' Code
( 910 n 296-1033
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 120
A rl 117
r M _
d. TOP OF CASING IS 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): 40 METHOD OF TEST BLDWED
f. DISINFECTION: Type CLOR(NE Amount 2-3"PJLL;
g. WATER ZONES (depth):
Top 100 Bottom 120 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 110 Bottom 120 Ft. 4 SC40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. BENTONITE POORED
Top Bottom Ft.
Top BottomFt.
9. SCREEN: Depth Diameter Slot Size Material
: Top 110 Bottom 120 Ft. 4 in. 15 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
•
10. SAND/GRAVEL PACK:
Depth Size Material
Top 100 Bottom 120 Ft. M E D SAND
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
• Top Bottom Formation Description
▪ 0 / 25
5 /93
•3 / 94
94 /100
100 / 120
/
/
/
/
2. REMARKS:
SAND
CLAY
ROCK
WATER SA v f°�
EIVED
ri
o 7102
JUN 11 2012
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 BEEN PROVIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES D NO CY :-SIGNATURE OF CERTIFIED WELL CONTRACTOR
c. WATER LEVEL Below Top of Casing: 40 FT.
(Use "+" if Above Top of Casing)
: JIMMY S QUINN
•
9-23-11
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09