412754_Well Construction - GW1_20130415

NON RESIDENTIAL WELL CONSTRUCTION RECORD 41 2 75 I
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION #: 4146A
1. WELL CONTRACTOR:
D.T. Chalmers, Jr.
Well Contractor (Individual) Name
CATLIN Engineers and Scientists
Well Contractor Company Name
220 Old Dairy Road
Street Address
Wilmington North Carolina 28405
City or Town State Zip Code
( 910) - 452-5861
Area code - Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT #: N/A
OTHER ASSOCIATED PERMIT # (if applicable): N/A
SITE WELL ID # (if applicable) DPT-01 (52-57)
3. WELL USE (Check One Box): Monitoring ® MunicipaVPublic ❑
IndustriaVCommercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation ❑ Other ❑ (list use)•
DATE DRILLED: March 04, 2013
4. WELL LOCATION:
3rd & A Streets, MCB, Camp Geiger, 28542
(Street Name, Numbers, Community, Subdivision, Lot No., -Parcel, Zip Code)
CITY: Jacksonville COUNTY: Onslow
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley ®Flat ❑Ridge ❑Other:
LATITUDE: 34.739712 DD
LONGITUDE: 77.456278 DD
Latitude/longitude source: IXI GPS 0 Topo. map
(Location of well must be shown on a USGS topo map and
attached to this form if not using a GPS.)
5. FACILITY (Name of the business where the well is located.)
N/A N/A
Facility Name Facility ID # (if applicable)
3rd & A Streets, MCB, Camp Geiger
Street Address
Jacksonville
City or Town
Ms. Jenni Reed
NC
State
28542
Zip Code
Contact Name
Attn: GF/ EMD/ EQB/ 12 Post Lane
Mailing Address
Camp Lejeune
City or Town
(910)- 451-5068
Area code - Phone number
NC
State
6. WELL DETAILS:
a. TOTAL DEPTH: 57
28542-0004
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing. 4.74 FT
(Use "+" if Above Top of Casing)
1:1
d. TOP OF CASING Ic 0.64 FT. Above Land Surface*
Top of easing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C.0118.
e. YIELD (gpm): WA METHOD OF TEST: WA
f. DISINFECTION: Type WA Amount: WA
g. WATER ZONES (depth):
Top
Top
Top
7. CASING:
Bottom
Bottom
Bottom
Top
Top
Top
Bottom
Bottom
Bottom
Thickness/
Depth Diameter Weight
Top 0 Bottom 52 Ft. 1 in. Sch. 40
Top Bottom Ft. in.
Top Bottom Ft. in.
8. GROUT:
Material
PVC
Depth Material Method
Top 50 Bottom 51 Ft. Bent. Pellets Surface Pour
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Top 52 Bottom 57 Ft. 1 in. Slot .010 in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Material
PVC
10. SAND/GRAVEL PACK:
Depth Size Material
Top 51 Bottom 57 Ft. #2 Medium Torpedo Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
12. REMARKS:
SEE
ATTACHED
WATER QUALITY SECTION
9vFCirIviK1 ION fktJCESSING UNIT
I 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.
2/C,fo4 5 2—l5
SIGNATURE OF CERTIFIED WEL DONTRACTOR ppTE
D.T. Chalmers, Jr. ki�)rk i ,,.
PRINTED NAME OF PERSON CONS',TRUCTING THE WELL
*47
APR 15 2013
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-1617, Phone No. [phone]
Modifitrom
Form OW -lb
-Rev. 2/09