414384_Well Construction - GW1_20130721

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc.
Well Contractor Company Name
9088 North Field Dr
Street Address
Fort Mill
SC 29707
City or Town State Zip Code
[phone]
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) 12
3. WELL USE (Check One Box) Monitoring 0f Municipal/Public 0
Industrial/Commercial 0 Agricultural [ Recovery D Injection 0
Irrigation❑ Other p (list use)
DATE DRILLED 6/13/13
4. WELL LOCATION:
267 Western Boulevard Jacksonville, NC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel Zip Code) Girt - - COUNTY On )1iSt t}
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
p Slope [Valley ❑Flat ❑Ridge ❑Other
LATITUDE 34.757805 " DMS OR 3X.XXXXXXXxX DD
LONGITUDE -77.381668 "DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: EGPS (]topographic map
(location of well must be shown on a USGS topo map andattached to
this form it not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Environmental Services and solutions
Contact Name
PO Box 12055
Mailing Address
Wilmington NC 28405
City or Town State Zip Code
( 910. ) 470-7066.
Area code Phone number
6 WFLL DFTAILS.
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
3476
414384 1 6-0
d. TOP OF CASING IS 0 FT. Above Land Surface*
'Top of casing terminated atfor 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 2 Bottom 12 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 2 Bottom 12 F1. 2" 40 pvc
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 1 Ft, portland pour
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 2 Bottom
Diameter Slot Size Material
12 Ft. 2 in. 010 in. pvc
Top Bottom Ft. inin.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth Size Materiel
Top 1.5 Bottom 12 Ft. #2 sand
Top Bottom Ft,
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 12
sand
12. REMARKS:
shallow water table 2'
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
i5A11CAC2C WELL UONbIRULLLMLBLANDAHUSANLAHh1ALue1'DF1NIS.__.
RECORD HAS BEEN PROVIDED 10 THE WELL OWNER
siedo
6/17/2013
CERTiFiED WELL CONTRACTOR DATE
Randy Hoffman
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-lb
Rev. 2/09