411117_Well Construction - GW1_20130204

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Bobbie Fowler
Well Contractor (Individual) Name
Mid -Atlantic Drilling Inc.
Wet 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
State
28428
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW- 2
3. WELL USE (Check One Box) Monitoring i Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
irrigation❑ Other ❑ (list use)
DATE DRILLED 12/18/2012
4. WELL LOCATION:
510 Viilaae Road
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Leland COUNTY Brunswick
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley iifFlat ❑ Ridge ❑ Other
Kc F$TCD 34 iA14^"8126 pgAAA! CL R OR AAAAAA.AAAAAAA cc
KNMF t$TCD 78 iAOAA&3.903 `AA! CL R OR AAAAAAAAAAAAA CC
Latitude/longitude source: ❑GPS Vropographic 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.)
Crescent State Bank Leland Property
Facility Name Facility ID# (if applicable)
510 Viilaae Road
Street Address
Leland NC 28451
City or Town State Zip Code
Keith Betts
Contact Name
1508 Military Cutoff Road
Mailing Address
Wiiminatop NC 28405
City or Town State Zip Code
( 910,E 344-2265
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 18
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 10.36
(Use "+" if Above Top of Casing)
NO q/
FT.
2869-A
411117
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
: Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top 0 Bottom 8 Ft. 2" Sch 4C PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 3 Bottom 6 Ft. bentonite
Top 0 Bottom 3 Ft concrete
Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
Weight
Material
Method
pour
pour
9. SCREEN: Depth Diameter Slot Size Material
Top 8 Bottom 18 Ft. 2 in. 0.01 in. pvc
Top Bottom
: Top Bottom
: 10. SAND/GRAVEL PACK:
Depth
Top 6 Bottom 18
Top Bottom
: Top Bottom Ft.
▪ 11. DRILLING LOG
Top Bottom
0 /2
2 /4
4 /6
6 /12
12 / 16
16 / 18
/
/
12. REMARKS:
Ft.
Ft.
in. in.
in. in.
Size Material
Ft. #2 torpedo sand
Ft. natural pack
Formation Description
Tan medium sand
Gray sandy clay
Orangish tan medium sand
Gray fine and medium sand
Tannish pray fine and med. sand
Yellowish orange fine and
medium sand
er
2013
I DO HEREBY CERTIFY THAT THIS WELL WAS CbN$TRUCTED IN ACCORDANCE TH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARD D THAI-A-COPY OF THIS
: RECORD HAS BEEN PROVIDED TO THE WELL OWNE
12/20/12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Bobbie Fowler
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 27699-161 Phone ; [phone]
' - r :Form-dtr1
JAN