414104_Well Construction - GW1_20130618

NONRESJDENTIAL WELL CONSTRUCTION RECORD
North Carolina .Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2593
1. WELLCONTRACTOR:
Rich Lemire
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
9088 NORTHFIELD DR
Street Address
FORTMILL
SC 29707
City or Town State Zip Code
) [phone]..
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) _ - MW-6
3, WELL USE (Check One Box) Monitoring M Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery p Injection J
IrrigationD Other p (list use)
DATE DRILLED 5-23-2013
4. WELL LOCATION:
945 Main Street Fair Bluff, North Carolina
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: FAIR BLUFF - - - COUNTY COLUMBUS
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope 0 Valley 0 Flat o Ridge 0 Other
LATITUDE 34.314806 DMS OR 3x.xxxxxxxxx DD
LONGITUDE -79.033162 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: 23PS :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.)
GAS STATION
Facility Name
945 MAIN STREET
MW-6
Facility ID# (if applicable)
Street Address.
FAIR BLUFF
NC
City or Town
AUSTIN HEWITT
State Zip Code
Contact Name
7900-D STEVENS MILL RD #120
Mailing Address
MATTHEWS
NC 28104
City or Town
( 704 ) 877-3541
Area code Phone number
a. TOTAL DEPTH:
9
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO z
c. WATER LEVEL Below Top of Casing: , _ .
(Use if Above Top of Casing)
FT.
•
•
1 � � e
Cj
4141.04
d. TOP OF CASING IS 0 FT. Above Land Surface*
*Top of casing terminated et/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 -
g. WATER ZONES (depth):
: Top Bottom. Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 4 Ft, 2 SCH40 PVC
Top Bottom
Top Bottom
8. GROUT: Depth
Top 0
Top Bottom Ft.
Top Bottom Ft.,
Bottom 3
Ft.
Ft.
Material
Ft. PORTLAND
Method
POURED
9. SCREEN: Depth Diameter Slot Size Material
Top__4_.,....___ Bottom _.....g .._.. Ft. 2 _in, . 010 in. PVC
Top Bottom Ft. in. in,
Top Bottom R. in.
in.
Material
: Top 3.5 SAND
Top
Top Bottom ' Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
0 / 9 SAND
10. SAND/GRAVEL PACK:
Depth Size
Bottom 9 Ft. #2
Bottom Ft.
/
/
/
/
/
/
t 1F,l 1 0 201'3-
WAXER QUALATY SECTION
INFORMATION PROCESSING UNIT.
: 12. REMARKS:
: BENTTONITE FROM 3.0'-3.5'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN_ACCoRDANCEVJ_!TH________
15A NCAC2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECORD HAS BEEN PROVIDED TO THE WELL O1lr! .
•
_' �~ �5,
.• frA .*lye ij
SIGNA:1-UP U CER � ii:IED WELL COORAC R
r I►i
RICHY L LEMIRE o '
PRINTED NAME OF PERSON CONST pTING 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 G
Rev. 2/09