413511_Well Construction - GW1_20130514

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1. WELL CONTRACTOR:
William M. Wiaciins
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3470-A
Well Contractor (Individual) Name
Mid -Atlantic Drilling Inc.
Well Contractor Company Name
P.O. Box 315
Street Address
Carolina Beach
City or Town
(910 ) 458-5020
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28428
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-1
3. WELL USE (Check One Box) Monitoring rif Municipal/Public
Industrial/Commercial 0 Agricultural 0 Recovery El Injection
Irrigationo Other 0 (list use)
DATE DRILLED 05-02-2013
4. WELL LOCATION:
121 Central Blvd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Hanova
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
lope oValley D Flat 0 Ridge DOther
KgIST CD 34 i 139A A190501644A A A I CL R OR AAAAAAAAAAAAA cc
KN MF EST CD 77 AC4A tAgAmeeteo‘ ! CL R OR AAAAAAAAAAAAA cc
Latitude/longitude source: OGPS :Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Central Blvd_ 121
Facility Name Facility ID# (if applicable)
121 Central Blvd_
Street Address
Wilmington
City or Town
Willie GreAn
NC
State Zip Code
Contact Name
121 Central Blvd_
Mailing Address
Wilmington
City or Town
91016 231-1816
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 19
NC
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO rif
c. WATER LEVEL Below Top of Casing: 11 FT.
(Use "+" if Above Top of Casing)
: d. TOP OF CASING IS - 0.5 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
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
: 7. CASING: Depth
Top 0 Bottom 9
Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth
Top 5 Bottom 6
i Top 0 Bottom 1
Amount
Top Bottom
Top Bottom
Top Bottom
Thickness/
Diameter Weight Material
Ft. 2 in Sch 4C PVC
Material
Ft. Bentonite
Method
Pour
Ft. Concrete Pour
Top Bottom Ft.
9. SCREEN: Depth
Top 9 Bottom 19
Top Bottom
Top Bottom
Diameter Siot Size Material
Ft. 2 in. .01 in. PVC
Ft. in. in.
Ft. in. in.
: 10. SAND/GRAVEL PACK:
• Depth Size
Top 6 Bottom 19 Ft. #2
Top 1 Bottom 5 Ft. Natural Pack
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
•
/
/
/
/
12. REMARKS:
Material
Torpedo sand
Formation Description
Fill Sand
Reddish Brown Med. Sand
Brown Med. to Fine Sa d
,
tr%
WIA,:f I 4 Z013
•
: 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 HAS :EEN PROVI' , ID • T ELL OWNER.
ILA .• , /3'
SI NATURE OF CERTIFIED WELL Cf) RA OR DATE
: William M. WiQgins
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-lb
Rev. 1/08