411882_Well Construction - GW1_20130225

❑Slope ❑Valley ii"F at ❑Ridge ❑Other
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2540-A
1. WELL CONTRACTOR:
Jeffrey A Stewart
Well Contractor (Individual) Name
Mid -Atlantic Drilling Inc.
Well Contractor Company Name
PO 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 d Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 01/24/2013
4. WELL LOCATION:
522 Wayne Drive
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY N.H.0
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Itd i TCD 34 A : ;wGY00^1 CL R OR 3X^XXXXOCIVOX E CC
KN MF I$TCD 77 lr^ 61208+0000^^ r. CL R OR AtMeX )tx e CC
Latitude/longitude source: COPS DTopographic 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.)
Wayne Dr. - 522 N/A
Facility Name Facility ID# (if applicable)
522 Wayne Drive
Street Address
Wilmington NC 28403
City or Town State Zip Code
Jack Swart
Contact Name
PO Box 186
Mailing I ddress
Jacksonville
City or Town
( 910. 358-2851
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 19.5
NC 28541
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO q%
c. WATER LEVEL Below Top of Casing: 14
(Use "+" if Above Top of Casing)
FT.
411882
d. TOP OF CASING IS -0.25 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
g. WATER ZONES (depth):
: Top Bottom Top
: Top Bottom Top
: Top Bottom Top
7. CASING: Depth Diameter
Top 0 Bottom 9.5 Ft. 2"
Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth Material
Top 7 Bottom 8 Ft. bentonite
Top 0 Bottom 1 Ft. concrete
Top Bottom Ft.
9. SCREEN: Depth
Top 9.5 Bottom
Bottom
Bottom
Bottom
Weight
Sch 4C
Material
PVC
Method
pour
pour
Diameter Slot Size Material
19.5 Ft. 2 in. 0.01 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
: Top 8 Bottom 19.5
Size Material
Ft. #2 torpedo sand
Top 1 Bottom 7 Ft.
Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
•
•
•
•
•
•
0 /12
natural pack
Formation Description
fill sand
12 / 15 light brown sand med. sand
.15 _____/ Via.. ^r^1.oe. crey sil cla _ ,
18 / 20 green to orange wet clay
/ w/ abundant shell fragments
/
/
12. REMARKS:
and limestone layers
FE . 8 2013
I DO HEREBY CERTIFY THAT THIS WELL WA ONS
• 15A NCAC 2C, WELL CONSTRUCTION STAND
: RE ► D : EEN PROVID TO THE WEL r• ` DINER.
•
•
S ��A 1� •'CER IFEDWE
Jeffrey A Stewart
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
S, AND THAT A COPY OF THIS
211-21i 3
CONTRACTOR DATE
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-1b
Rev. 1/08