413071_Well Construction - GW1_20130422

N ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2487
1. WELL CONTRACTOR:
Arnold Chapel
Well Contractor (Individual) Name
Parratt-Wolff, Inc.
Well Contractor Company Name
501 Millstone Drive
Street Address
Hillsborough
City or Town
(919 ) 644-2814
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC
State
27278
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) AS-2
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other i(Iist use) Air SDarae
DATE DRILLED 3/27/13
4. WELL LOCATION:
NC Hiahwav 50
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Chinauaoin COUNTY DUDlin
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley geFlat ❑Ridge ❑Other
LATITUDE 34 "DMS OR 34.80259924 DD
LONGITUDE 77 " DMS OR 77.78214097 DD
Latitude/longitude source: ❑GPS Q1Topographic 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.)
Marie & Billv's Grill
Facility Name Facility ID# (if applicable)
4463 NC Hiahwav 50
Street Address
Chinauanin NC 28521
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20.0'
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 4.0
(Use "+" if Above Top of Casing)
NO qf
FT.
.... ...........................
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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 15.0 Ft. 2" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 11.0 Ft. Portland Tremie
Top 11.0 Bottom 13.0 Ft. Bentonite Tremie
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 15.0 Bottom 20.0 Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size
: Top 13.0 Bottom 20.0 Ft. #1
Top Bottom Ft.
; Top Bottom Ft.
Material
Sand
: 11. DRILLING LOG
: Top Bottom Formation Description
No samples taken
/
/
/
/
/
/
•
12. REMARKS:
'11 . e'i
L. tF i
`PC`.Z.5Cf C,j' 1JNt t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A N AC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECD HAS BE ROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
Arnold Chapel
411idt5
DATE
PRINTED NAME OF P'ERSOi ONSRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone ; [phone]
Information Processing,
013 Form GW-1 b
Rev: 2/09

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NOTES:
1. MAP SCALE AND SITE FEATURES ARE APPROXIMATE.
TITLE FIGURE 1
SITE MAP
FORMER MARIE AND BILLY'S GRILL
4463 NORTH CAROLINA HIGHWAY 50
CHINQUAPIN, NORTH CAROLINA 28521
YATC
ASSOCIATES INC.
Raleigh, North Carolina 27604 [phone] FAX [phone]
CAD FILE
1253867.DWG
TYPE CODE
PREP. BY
RK
REV. BY
RK
SCALE
1" = 40'
DATE
03-21-2013
PROJECT NO.
45.40675.5002