414102_Well Construction - GW1_20130617

NON RESIDENTIAL WELL CONSTRICTION 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
41/'1102
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 2,C .0118.
SAEDACCO Inc METHOD OF TEST
e. YIELD (gpm):
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) MWnT-4
3. WELL USE (Check One Box) Monitoring 3 Municipal/Public El
industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
IrrigationD 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- COLUUS
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
0 Slope °Valley 0 Flat 0 Ridge 0 Other
LATITUDE 34.314806 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE -79.033162 DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: 1103PS DTopogtaphic map
(location of well must be shown on a USGS topo map andaitached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
GAS STATION
MW-4
Facility Name Facility ID# (if applicable)
945 MAIN STREET
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 State Zip Code
( 704 ) .. 877-3541
Area code Phone number
--
a. TOTAL DEPTH: 9
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use a+" if Above Top of Casing)
YES D NO X
FT.
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top_ ,. Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7, CASING:. Depth Diameter
: Top 0 Bottom 4 Ft, 2
Top Bottom Ft.
Top Bottom Ft.
8_ GROUT: Depth
: Top 0 Bottom 3
Material
Ft, PORTLPND
Thickness/
Weight Material
SCH40 PVC
Top Bottom Ft.
Top Bottom Ft..
Method
POURED
9. SCREEN: Depth Diameter Slot Size
Top 4 Bottom 9 Ft, 2 in, 010 in.
Top Bottom Ft. in. in.
Top Bottom Ft. in, in.
: 10. SAND/GRAVEL PACK:
Depth
: Top 3.5 Bottom
Top Bottom
Material
PVC
Size Material
9 Ft- #2 SAND
Ft.
Top Bottom
: 11. DRILLING LOG
Bottom Formation Description
: Top
•
•
•
/j
e
Ft.
0 / 9
/
/
/
/
1
/
SAND
Y: Yt t a 1 AO \J
INFORMATION PROCESSING SSING UNIT
12. REMARKS:
: BENTONITE FROM 3.0'-3.5'
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
5A NCAC 2C. WELL CONSTRUCTION .STANDARDS..ANO-THAT. A COP'( O Ti a.
• RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
5/25/2013
• SIGNA'WO. OI L;ER IFiED WELL CONTRACTOR DATE
RICHY L LEMLRE a�
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