412129_Well Construction - GW1_20130311

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NON RESIDENTIAL WELL CONSTRUCTION RECORD
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 #:
OTHER ASSOCIATED PERMIT # (if applicable): N/A
SITE WELL ID # (if applicable) GP2
3. WELL USE (Check One Box): Monitoring ® MunicipaVPublic ❑
IndustriaVCommercial ❑ Agricultural ❑ 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 DOther:
LATITUDE: 34.1829 DD
LONGITUDE: -77.9509 DD
Latitude/longitude source: ® 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.)
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): WA METHOD OF TEST: N/A
f. DISINFECTION: Type WA Amount: N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING:
Depth
Thickness/
Diameter Weight
Top 0 Bottom 0 Ft. 2 in. Sch.40
Top Bottom Ft. in.
Top Bottom Ft. in.
8. GROUT:
Material
PVC
Depth Material Method
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN:
Depth Diameter Slot Size
Top 0 Bottom 10 Ft. 2 in. Slot .010 in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Material
PVC
• 10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
• Top Bottom Ft.
Top Bottom Ft.
• 11. DRILLING LOG
• Top Bottom
N/A N/A
Facility Name Facility ID # (if applicable)
Street Address
Wilmington NC
State
City or Town
Zip Code
Contact Name
Mailing Address
City or Town State
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 10
Zip Code
/
/
Formation Description
/ WATER QUALITY SECTION
/ gFnRMAT1ON PROCESSING UNIT
� SE
12. REMARKS:
.ATTACHED
AR H 2013
• 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 IXI
c. WATER LEVEL Below Top of Casing: , FT. • SIG
(Use "+" if Above Top of Casing)
-/-/3
UE 0 CERTIFIE ' WELL CONTACTOR
: D. . 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-1b
Rev. 2/09