411705_Well Construction - GW1_20130218

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2730-A
1. WELL CONTRACTOR:
Kelly Grant
Well Contractor (Individual) Name
American Environmental Drilling, Inc.
Well Contractor Company Name
324 Fields Drive Suite C
Street Address
Aherdeen NC 211315
City or Town State Zip Code
L910 I- 944-3140
Area ccde- Phone ruttier
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT #
OTHER ASSOCIATED PERMIT #(if applicable)
SITE WELL ID #(if applicable) DW-I
3. WELL USE (Check Applicable Box) Monitoring El Municipal/Public 0
Industrial/Commercial O Agricultural 0 Recovery 0 Injection 0
Irrigation 0 Other O (list use)
DATE DRILLED 12-28-12
4. WELL LOCATION:
3498 OLD WILMINGTON HWY
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: VERONA COUNTY ONSLOW
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope OValley ®Flat ORidge OOther
LATITUDE 34° 39" 17.37" - DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77° 29" 52.58" "DMS OR 7X.XXXXXXXXX DD
Laiirudcrlongitude source ®G PS 0 Topographic Inap (location of
well must be shown on a USGS topo map and attached to this limn
if not using GPS)
5. FACILITY- is the name of the business where the well is located.
VERONA QUICK MART
Facility Name
3498 OLD WILMINGTON HWY
Facility ID Nil applicable)
Street Address
VERONA
nc 28365
City or Town State
SCOTT DRISCOLL(E.J.POPE
Contact Name
P,O. DRAWER 649
Zip Code
Mailing Address
MT.OLIVE NC 28365
City or Town State
t j
Area ccde - Phone number
6. WELL DETAILS'
v--IGff*L®'IH-1 40'
411705
d. TOP OF CASING IS -.6 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
8
7. CASING:
Top 0
Top
Top
WATER ZONES (depth):
Top 30 Bottom 40 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
Depth Diameter Weight Material
Bottom 30 Ft.6 SCH40 PVC
0 Bottom 35 Ft 2 SCH40 PVC
Bottom FL
8. GROUT: Depth
Top 0 Bottom
Top 30 Bottom
Top Bottom
9. SCREEN:
Top 35
Top
Top
Depth
Bottom
Bottom
Bottom
10. SAND/GRAVEL PACK:
Depth
33 Bottom
Bottom
Bottom
Top
Top
Top
11. DRILLING LOG:
Top Bottom
0
5
8
l5
/8
/31
31
/ 40
12. REMARKS
Material Method
30 Ft NEAT CEMENT TRFMIE
33 Ft RENTONITE POUR
Ft
Diameter Slot Size Material
40 Ft.2 in. .010 in. PVC
Ftin. in.
Ftin. in.
Size Material
40 Ft 43 SAND
Ft
Ft
Formation Description
BLACK SANDY CLAY
BROWN SANDY CLAY
GRAY SANDY CLAY
GRAY LIMESTONE AND CLAY
N4 r( 9
E IVF:' `r
FEB 9�iikfMmation Processing L)fttt
DWA°QIBQr`-`
Zip Code I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD IIAS BEEN PROVIDED TO THE WELL OWNER
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing:2,4 FT.
(Use "+" if Above Top of Casing)
7(
SIGNATURE OF C.
Kelly Grant
TIFIED WELL CONTRACTOR
12-28-12
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to the Division of Water Quality - Information Processing,
1617 ,Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone]
DATE
Form GW-lb
Rev. 2/09