414099_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
( ) [phone]
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#Of applicable)
SITE WELL ID #(if applicable) -1
3. WELL USE (Check One Box) Monitoring X Municipal/Public 0
Industrial/Commercial CJ 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 COLUMBUS
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
0 Slope :Walley 0 Flat °Ridge .D Other
LATITUDE 34.314806 " DMS OR 3x.xxxxxxxxx DD
LONGITUDE -79.033162 " DMS OR 7x.xxxxxxxxx DO
Latitude/longitude source: 13P5ropographic map
(location of well must be shown on a USGS topo map andattached to
This form it not using GPS)
5. FACILITY (Name of the business where the well is located.)
GAS STATION MW-1
Facility Name Facility JD# (if applicable)
945 MAIN STREET
Street Address
FAIR BLUFF NC
City or Town State Zip Code
AUSTIN HEWITT
Contact Name
7 90 0 -D STEVENS MILL RD # 12 0
Mailing Address
MATTHEWS NC 28104
City or Town State Zip Code
( 704 ) 877-3541
Area code Phone number
:._WELL DETAILS:
a. TOTAL DEPTH: 9
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Z
c. WATER LEVEL Below Top of Casing:._. _._..
(Use `+" if Above Top of Casing)
FT.
ci
414099
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_- _ -
Top Bottom Top
Top Bottom Top
Thickness/
7, CASING: Depth Diameter Weight Material
Top 0 Bottom 4 Ft.2 SCH40 PVC
Bottom
Bottom
Bottom
Top Bottom
Top Bottom
8, GROUT: Depth
Top 0 Bottom 3
Top Bottom Ft.
Top _ _. Bottom, - Ft.
Ft.
Ft.
Material
Ft. PORTLAND
9. SCREEN: Depth Diameter
Top 4 Bottom --. 9 Ft. 2 in.
Top Bottom Ft. in.
Top_, Bottom
Method
POURED
Slot Size Material
.010in. PVC
10. SAND/GRAVEL PACK:
Depth
: Top 3.5 Bottom
Top Bottom Ft.
Size
9 Ft. # 2
: Top Bottom Ft.
: 11. DRILLING LOG
: Top Bottom
•
0 /
/
/
/
/
/
/
/
9
: 12. REMARKS:
: BENTONITE FROM
in.
in.
Material
SAND
Formation Description
SAND
rAV
JU 1 7 2013
WATER rQUUA,LI Y SECTION
INFORMATION PROCESS G UN;
3.01-3.5'
{ 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 OViaNER_
,-..-----1
. ,i.
. ___-_,__..:-, - .,,, .
SIGNAThR :.OF CER.,,,, , ..., I iED WELL CONTRACTOR
RICHY L DIRE
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]
5/25/2013
DATE
Form GW-lb
Rev. 2/09