412461_Well Construction - GW1_20130502

ON ESDENT L WELL CONSTRUCTION '' ECORD
North Carolina. Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 34 7O -A
1. WELL CONTRACTOR:
William M Wiaains
Well Contractor (Individual) Name
Mid -Atlantic Drillin Inc.
Well Contractor Company Name
POBox315
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) M V-1
3. WELL USE (Check One Box) Monitoring ii Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 03/12/2013
4. WELL LOCATION:
2,.. GL
: 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): NA 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 5 Ft. 2" Sch 4( PVC
Top Bottom Ft.
: Top Bottom Ft.
. 8. GROUT: Depth Material Method
Top 0 Bottom 1 Ft. bentonite pour
Top 1 Bottom 3 Ft. concrete pour
i Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
7140 Hiahwav 17 : Top 5 Bottom 15 Ft. 2 in. 0.01 in. pvc
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) '
Top Bottom Ft. in. in.
CITY: Grissettown COUNTY Brunswick ; Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope o Valley (Fiat ❑ Ridge ❑Other
LATITUDE 33 ° 56 ' 48.0200 "DMS OR DD
LONGITUDE 78 ° 30 5 13.2100 DMS OR DD
Latitude/longitude source: VGPS ViTopographic 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.)
Parker Properly N/A
Facility Name Facility ID# (if applicable)
7140 Hiahwav 17
Street Address
G ri s ettown
City or Town
Gres Gore
Contact Name
502 SunsQt Boulevard
Mailing Address
Sunset Beach
City or Town
( 910J5 443-1856
NC
State Zip Code
NC 28468
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 15
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 5(
c. WATER LEVEL Below Top of Casing: 5.65 FT.
(Use "+" if Above Top of Casing)
1• 0. SAND/GRAVEL PACK:
Depth Size Material
Top 3 Bottom 15 Ft. #2 torpedo sand
Top Bottom Ft. natural pack
: Top Bottom Ft.
•
• 11. DRILLING LOG
Top Bottom Formation Description
0 /8
8 /15
/
/
/
/
12. REMARKS:
Brown. slightly silty fine sand
Dark gray, clayey fine sand
OFOfMATKW P JC S.
1 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.
3/19/13
SIG"ATURE GF CERTIFIED WELL CO ,1 CTOR DATE
: William M WiQgjns
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]
Form GW-1 b
Rev. 2/09