411922_Well Construction - GW1_20130304

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3322-A
1. WELL CONTRACTOR:
Lawrence D. Opper
Well Contractor (Individual) Name
Regional Probing Services
Well Contractor Company Name
STREET ADDRESS PO Box 1161
Wake Forest, NC 27588
City or Town State Zip Code
( 919 )_ 570-5588
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-8R
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ® Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 1/16/2013
TIME COMPLETED N/A
3. WELL LOCATION:
CITY: Winnabow (Leland)
8 Sloan Rd. SE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope ❑ Valley E Flat 0 Ridge ❑ Other
(check appropriate box)
LATITUDE 3 N34.18165
LONGITUDE W78.08252
Latitude/longitude source: ❑ GPS
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY D&J's Exxon
STREET ADDRESS 8 Sloan Rd. SE
AM ❑ PM
COUNTY Brunswick
May be in degrees,
minutes, seconds or
in a decimal format
Winnabow (Leland),
❑ Topographic map
NC 28451
City or Town State Zip Code
CONTACT PERSON NCDENR DWM UST Section
MAILING ADDRESS 1637 Mail Service Center, Raleigh, NC
Raleigh, NC 27699
City or Town State Zip Code
( 919 )_ 707-8200
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 15'
b. DOES WELL REPLACE EXISTING WELL? YESig NO21
c. WATER LEVEL Below Top of Casing: -10 FT.
(Use "+" if Above Top of Casing)
6. CASING:
n 2, 2,
d. TOP OF CASING IS .10 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 NA
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
Thickness/
Depth 2Qiameter srg4 Qllagrial
From 0 To Ft, Pvvtt;;
From To Ft.
From To Ft.
7. GROUT: Depth
From 0 To 3
Material
Ft.cement
Amount
From 3 To 4 Ft. bentonite
From . To Ft.
pour
pour
Method
8. SCREEN: Depth Diameter Slot Size Material
From 5 To 15. Ft.2 in. .010 in PVC
From To Ft. in. in.
From .. To .. Ft. in. in.
•
9. SAND/GRAVEL PACK:
Depth Size Material
From 4 . To 15.. . Ft. #2 Sand
From . To Ft.
From To . Ft.
10. DRILLING LOG
From To Formation Description
0-15' interbedded silty sand and clav
11. REMARKS:
F 2 2 2013
imun4v tuon Processing Uno.
DWO/OG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NC 2C, W CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOPROVIDED TO THE WELL OWNER.
ATU
E
3 13
F CERTIFIED WELL CONTRACTOR DATE
.2c ,77-7 (72,77-77\ /7 7, 7:—
PRINTED NAME OF PERS ONSTR`QfT1G "'Mt WE'LL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,:
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
MAR 0 4 2013
r
Form GWb
Rev. 7/05`t,"`