410454_Well Construction - GW1_20131213

NONRESIDENTIAL WELL CONSTRUCTION RECORD fl
Department of Environment and NaturalResources- -5 4,North Carolina
esources Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2869-A
1. WELL CONTRACTOR:
Bobbie Fowler
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-3
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationo Other ❑ (list use)
DATE DRILLED 1 1 /12/2012
4. WELL LOCATION:
1624 Castle Havne Road
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY N.H.0
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
['Slope ❑ValleyFlat ❑ Ridge DOther
LATITUDE 34 0 16 , 1.2300 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 77 ° 55 , 46.8400 " DMS OR 7X.X00000000X DD
Latitude/longitude source: ❑GPS Wifropographic 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.)
Castle Havne Road -1624 N/A
Facility Name Facility ID# (if applicable)
1624 Castle Havne Road
d. TOP OF CASING IS 0 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 Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom Ft. 2" Sch 4C PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.5-1 Bottom Ft. bentonite pour
Top 0-0.5 Bottom Ft. concrete pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top 2 Bottom 12 Ft. 2 in. 0.01 in. pvc
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
• Depth Size Material
Top 1 Bottom 12 Ft. #2 torpedo sand
Top Bottom Ft. natural pack
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
0 / 8 Dark brown fine sand
•
Street Address
Wilminaton NC 28401
City or Town State Zip Code : /
Randv Burae = /
Contact Name : /
1117 Military Cutoff Road
8 /12
/
/
Mailing Address •
Wilminaton NC 28405
City or Town State Zip Code
( 910i 509-3918
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES ❑
NO qI
c. WATER LEVEL Below Top of Casing: 5.01
(Use "+" if Above Top of Casing)
FT.
/
• 12. REMARKS:
Tan fine sand
?(J12
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• REC RD HAS BEEN PROVIDED TO THE WELL OWNER.
(() 1.1,/12/1.2
SIUNATURE OF CE TIRED WELL CONTRACTOR,':DATE ` '.•
Bobbie Fowler
PRINTED NAME OF PERSON CONSTRUCT! EV tEl_LZU1a
Submit within 30 days s of completion to: Division of Water Quality - Information Processing ---��'
Y p tY g� „ r Rev. 2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]