412131_Well Construction - GW1_20130311

NON RESIDENTIAL WELL CONSTRUCTION RECORD 4 '- `' I
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION #: 4146A
1. WELL CONTRACTOR:
D.T. Chalmers, Jr.
Well Contractor (Individual) Name
CATLIN Engineers and Scientists
Well Contractor Company Name
220 Old Dairy Road
Street Address
Wilmington North Carolina 28405
City or Town State Zip Code
( 910 ) - 452-5861
Area code - Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT #: N/A
OTHER ASSOCIATED PERMIT # (if applicable): N/A
SITE WELL ID # (if applicable) G P-4
3. WELL USE (Check One Box): Monitoring ® MunicipaVPublic 0
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection ❑
Irrigation ❑ Other ❑ (list use) -
DATE DRILLED: January 29, 2013
4. WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY: New Hanover
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑ Valley ® Flat ❑ Ridge ❑ Other:
LATITUDE:
LONGITUDE.
34.1828 DD
-77.9509 DD
Latitude/longitude source: ►:1 GPS ❑ Topo. map
(Location of well must be shown on a USGS topo map and
attached to this form if not using a GPS.)
5. FACILITY (Name of the business where the well is located.)
N/A
Facility Name
d. TOP OF CASING IS 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): N/A METHOD OF TEST: WA
f. DISINFECTION: Type N/A Amount: N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Thickness/
Depth Diameter Weight Material
Top 0 Bottom 0 Ft. 2 in. Sch. 40 PVC
Top Bottom Ft. in.
Top Bottom Ft. in.
8. GROUT:
Depth Material Method
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN:
Depth Diameter Slot Size Material
. Top 0 Bottom 10 Ft. 2 in. Slot .010 in. PVC
• Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
• 10. SAND/GRAVEL PACK:
Depth Size Material
: Top Bottom Ft.
• Top Bottom Ft.
Top Bottom Ft.
• 11. DRILLING LOG
Top Bottom Formation Description
N/A
Facility ID # (if applicable)
Street Address
Wilmington NC
State
City or Town
Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 1 0
/
MAR m 2O3
SEE,. WATER QUALITY SECTION
/
/
' 12. REMARKS:
=ATTAC
F P !TiON PROCESSING UNIT
AR 1 2O3
• 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 BEEN PROVIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ® .
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
SIG �� TURE 0 CERTIFIED ELL CONTRACTOR
D.T. Chalmers, Jr.
DATE
: 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 27699-1617, Phone No. [phone]
Modified from
Form GW-1 b
Pwv 2/(1q