414103_Well Construction - GW1_20130617

NONRESJDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and .Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2593
1. WELL CONTRACTOR:
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
( ) (704)_ 507-1922,
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable
SITE WELL ID #(if applicable) MW-5 •
3. WELL USE (Check One Box) Monitoring 3 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation[ Other 0 (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)
El Slope o Valley 0 Flat cj Ridge D Other
LATITUDE 34.314806 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE -79.033162 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: I3PS DTopographic map
(location of well must be shown on a USGS topo map ands/cached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
GAS STATION
MW-5
Facility Name Facility JD# (if applicable)
945 MAIN STREET
Street Address
FAIR BLUFF
NC
City or Town
AUSTIN HEWITT
State Zip Code
Contact Name
7 9 0 0 -D STEVENS MILL RD # 1 2 0
Mailing Address
MATTHEWS
NC 28104
City or Town State Zip Code
( 704 ) 877-3541
Area code Phone number
6.WELL. DETAtLSS
a. TOTAL DEPTH:
9
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 6
(Use "+" if Above Top of Casing)
NO x
FT.
\f\k" (‘) c�
414i03
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): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
: Top 0 Bottom 4
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 3 Ft, PORTLAND
Thickness/
Diameter Weight Material
Ft. 2 SCH4 0 PVC
• Top... Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Method
POURED
Diameter Slot Size Material
Top 4...�._.. Bottom .... 9 Ft. 2 in, .010 in.
PVC
Top Bottom Ft. in. in.
; Top_ Bottom F
10. SAND/GRAVEL PACK:
Depth
= Top 3.5 Bottom 9
Size
Ft. #2
Top Bottom Ft.
Top Bottom Ft.
Material
SAND
: 11. DRILLING LOG
Top Bottom Formation Description
0 / 9 SAND
/
/
/
1
/
/
/
/
Mi ',E(1IU
-
N ORMATI N PROCESSING UNIT
: 12. REMARKS:
BENTONITE FROM 3.0'-3.5'
I DO HEREBY CERTIFY THAT THIS L' ELL_1NAS CONSTRUCTED. LACCO ANGE ITH_.._._._______
A, NCAC 2C. WELL CONSTRUCTION.STANDARDS. AND THAT A COPY OF THIS
- RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNAa P . OF CE' i IF JED WELL CONTRACTOR
: tc.)
5/25/2013
DATE
RICHY L LEMIRE
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]
Forrn GW-1 b
Rev. 2/09