411588_Well Construction - GW1_20130211

STATE, ;^
1. WtLL (:UN I RACTOR:
Sean Cropsey
.WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2485
Well contractor (Individual) Name
Skipper's Well Drilling & Pump Service, Inc.
Well Contractor Company Name
107 Oakland Avenue
Street Address
Leland
City or Town
910 3712770
NC 28451
State Zip Code
Area Code Phone Number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
SITE WELL ID# (if applicable)
3. WELL USE (Check Applicable Box): F
DATE DRILLED 01/14/2013
TIME COMPLETED AM®PME1
4. WELL LOCATION:
City: Rocky Point County Pender
A11,ri,08
• g. WATER ZONES (depth):
• Top 79 Bottom 59 Top Bottom
• Top _ Bottom_ Top _ Bottom
Top _ Bottom_ Top _ Bottom
Thickness/
7. CASING: Depth Diameter Weight
Top +2 Bottom 59 Ft. 2
Top _ Bottom_ Ft. _
Top Bottom Ft.
❑•
(Street Name, Numbers, Community, subdivision, Lot Nol, Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope EValley nFlatnRidge D Other
LATITUDE N34" 24. 985'
LONGITUDE W077" 55 . 514' '
Latitude/longitude source: ®GPS OTopographic map
(location of well must be shown on a USGS topo map and attached to
this form if not using GPS)
5. WELL OWNER
John Lee
Owner Name
65 Arvida Spur
Street Address
Rocky Point NC 28457
City or Town State Zip Code •
( 910 ) 6042008
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 79
b. DOES WELL REPLACE EXISTING WELL? YES
c. WATER LEVEL Below top of Casing:
8. GROUT: Depth
Top
Top
Top
0 Bottom
Bottom
Bottom
9. SCREEN:Depth
Top 59 Bottom
Top Bottom
Top — Bottom
20 Ft.
Ft.
Ft.
Material
Material
pvc
Method
Diameter Slot Size Material
79 Ft. 2 in.
in. pvc
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom
Top Bottom
Top Bottom
Size Material
Ft. Southern Products
Ft.
Ft.
11. DRILLING LOG
Top / Bottom Formation Description
0 / 10 clay
10 / 20 sand
20 / 30 -dark clay
50 / 79 sand, shells, clay layers
—I
—/
/
12. Remarks:
❑ NO®,
15 FT
(Use "+^ if Above Top of Casing)
d. TOP OF CASING IS 2 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
r rzn/
ED
G �I;'-�(m�>?ranorPrnce .,,g knit
�i oWQi
▪ I DO HEREBY CERTIFY TKO THIS WELL WAS CONSTRUCTED IN
• ACCORDANCE WITH 15A NC40,2C, WELL CONSTRUCTION
▪ STANDARDS, AND THAT A COi :ori—rils RECORD HAS BEEN
• PROVIDED TO THE WELL OWNER.
01/14/1:
• ▪ SIGNATURE OF CERTIFIED WELL CONTRACTOR - DATE
�t
i
PRINTED NAME F P SON CONSTRUCTING THE WELL
Submit within 30 days of completion to" Division of Water Quality - Information Pro Sssing Form GW-la
1617 Mail Service Center, Raleigh, NC 27699-161, Phone: [phone] Rev. 2/09