413510_Well Construction - GW1_20130514

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ofEnvironment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3470-A
1. WELL CONTRACTOR:
William M. Wiggins
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
d 1 5
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
State Zip Code
Area code Phone number Thickness/
2. WELL INFORMATION: 7. CASING: Depth Diameter Weight
WELL CONSTRUCTION PERMIT# N/A Top 0 Bottom 8 Ft. 2 in
NC 28428
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-1
3. WELL USE (Check One Box) Monitoring El Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigatipn0 Other 0 (list use)
DATE DRILLED 05-03-2013
4. WELL LOCATION:
125 Dupree Drive
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Hanove
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
lope EiValley 0 Flat 0 Ridge 0 Other
KOMI-CD 34 i /2/4AA patme00A I CL R OR AAAAAAAAAAAAA CC
KNMF ESTCD 77 i^n^815e03040^A! CL R OR AAAAAAAAAA AAA CC
Latitude/longitude source: D3PS I: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 (ocated.)
Dupree Drive- 125
Facility Name Facility ID# (if applicable)
125 Dunree Drive
Street Address
Wilminaton
City or Town
Katy Monaghan
NC
State Zip Code
Contact Name
6665 Trolley Lane
Mailing Address
Wilminaton
NC
City or Town State Zip Code
9106 262-0440
Area code Phone number
6,WELL DETAILS:
a. TOTAL DEPTH: 18
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO El
c. WATER LEVEL Below Top of Casing: 12 FT.
(Use "+" if Above Top of Casing)
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 1
: Top 5
Material
Ft. Concrete
Bottom
Bottom
Bottom
Material
Sch 4( PVC
Method
Pour
Bottom 6 Ft. Bentonite Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 8 Bottom 18 Ft. 2 in. .01 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
•
10. SAND/GRAVEL PACK:
• Depth Size Material
Top 6 Bottom 18 Ft. #2 Torpedo sand
Top 1 Bottom 5 Ft. Natural Pack
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
Formation Description
0 / 11 Fill Material
11 / 20 Light Brgwn Very Fine Sand
12. REMARKS:
with Mica
MAY 1
'7,11 11
C. I%)
kittAT-7.71 i`.); ;A
: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
' 5
: RECORD -HAS B EN PROVIDED TO THE WELL OWNER.
f
LA„IA,12, ,t,c, nivir -01elf
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SIGNATURE OF CERTIFIED WELL CONIRACTOR DATE
: William M. Wiggins
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. 1/08