411383_Well Construction - GW1_20130211

ON .ESI
ENTMIL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
■ YELL CONTRACTOR CERTIFICATION # 4110-
1. WELL CONTRACTOR:
Kirk McDonald
Well Contractor (individual) Name
Practical Environmental Solutions
Well Contractor Company Name
P.O. Box 12590
Street Address
Wilminciton
City or Town
(910 ) 790-8265
Area code Phone number .
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC
State
28405
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) 44
SITE WELL ID #(if applicable) iVittI t-ii
3. WELL USE (Check One Box) Monitoring Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other 0 (list u e)
DATE DRILLED I t'T f I
4. WELL LOCATION:
P.0.44.0tratk.
(Street Name, Numbers Community, Subdivision, Lot No., Parcel, Zip Code)
W C
CITY:� 1 t COUNTY dew tletkeAteir
t �
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley plat ❑ Ridge ❑Other
LATITUDE = '344 ° 2. ' 4630 " DMS OR 3X.XXX)0000 x DD
LONGITUDE tig 9° q(' ' qq" DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS :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.)
-kQVIacttt C'rg e. 3 2 0
Facility Name Facility ID# (if applicable)
AtMfe h C
Street Address
C,K) OVA -
City or Town
5CSalk
Contact Name
q PO8cr?1 55'.0
erz)ue4 •
State Zip Code
Mailing Address
1.�
G,P-t eke � S
City or Town
(It©)66 -45s3
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
Vc 2 443
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO V
c. WATER LEVEL Below Top of Casing: 16 FT.
(Use "+" if Above Top of Casing)
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
ji
d. TOP OF CASING IS V . 2 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 (gprn): METHOD OF TEST
f. DISINFECTION: Type • Amount
g. WATER ZONES (depth):
: Top
• Top
Top
:7. CASING:
Bottom
Bottom
Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
Depth Diameter Weight Material
Top Bottom t Ft. 2- Sc 40 PVC
Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth Mat rial , Method
Top Bottom 1 Ft.6Ft.
(-eh
Top Bottom � Ft. C
Top. Bottom Ft.
PPyr
; 9. SCREEN: Depth Diameter Slot Size
: Top ! 4 Bottom 2. Ft. 2 in. 0.6 1 in.
Top Bottom Ft. in. in.
Bottom Ft in. in.
Top
Material
ptfc
: 10. SAND/GRAVEL PACK:
f Depth
Top a Bottom 2
Size
Ft. —
: Top 1 Bottom B Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
� I►%5
12, REMARKS:
Formation Description
1i( So.kd
•
1 DO HEREBY CERTIFY T
: 15A NCAC 2C, WE L
: RECORD '►' S BE
T THIS WELL WAS
STRUCTION STAN
OVIDED TO THE WE L
SIGNA URE OF CERTIFIED W
D IN ACCORDANCE WITH
HAT A COPY OF THIS
1-2y-l3
CONTRACTOR . D , T
l'
E.r � 4i•
PRINTED NAME OF PERSON CONSTRUC4fNG THE WELL
I 2413
Form GW-1 b
1i� r