405533_Well Construction - GW1_20120606

1. WELL CONTRACTOR:
RESIDENTIAL 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# 169
NC 28572
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply [r
DATE DRILLED 11-18-1.1
TIME COMPLETED 4:45 AM ❑ PM [1
4. WELL LOCATION:
CITY: PINK HILL COUNTYDUPLIN
KOEACKER BRD
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley pi Flat ❑ Ridge ❑ Other
LATITUDE _ ,,;►-FP ?2-89 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE ,� �� 0' " 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. WELL OWNER
JONNY BALL
Owner Name
KITTY NOEACKER RD
Street Address
PINK HILL
City or Town State Zip: Code
(910 ) 324-4393
Area code Phone number
6. WELL DETAILS:
g. WATER ZONES (depth):
Top 170 Bottom 180 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top +1 Bottom 170 Ft. 2 SC40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 20 Ft. BENTONITE POORED
Top Bottom Ft.
. Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 170 Bottom 180 Ft.2in. 15 in, PVC
Top Bottom Ft. in, in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 165 Bottom 180 Ft. M E D SAND
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /23
23 /65
65 /120
120 /122
122 /160
160 /169
169 /170 WATER SAND
/
Formation Description
TOPSOIL -DIRT
SAND
BLUE CLSY
ROCK
CLAY -SAND -SHELL
BLUE CLAY
/
/
/
/
JUN I I 20i212. REMARKS:
J U N
!ntarMaiOn PrOCOSSirdj Unit
DN
a. TOTAL DEPTH: 180 •
.
b. DOES WELL REPLACE EXISTING WELL? . YES [Rr NOD,---
• I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 60 FT. : ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use "+" if Above Top of Casing) : STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS +1 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): 12 METHOD OF TEST BLOWED
f. DISINFECTION: Type CLORINE Amount 2-3"PILL6
10-4-11
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
JIMMY S QUINN
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-la
Rev. 2/09