NC0006254_MW-5 Monitoring Well Construction Record (GW-1)_20110826

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: NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3367 i i
1. WELL CONTRACTOR:
Gary Ellingworth
Well Contractor (Individual) Name
Parratt-Wolff, Inc.
Well Contractor Company Name
501 Millstone Drive
Street Address
Hillsborough NC 27278
City or Town State Zip Code
9( 19 ) 644-2814
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-5
3. WELL USE (Check One Box) Monitoring 4 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 8/16/1 1
4. WELL LOCATION:
2170 Florian Place
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Lenoir
COUNTY Caldwell
TOPOGRAPHIC / LAND SETTING:
(check appropriate box)
❑ Slope OValley ❑ Flat ❑ Ridge
❑ Other
LATITUDE 36 ° 0 - 76.0000
^ DMS OR 3X.XXXXXXXXX DID
LONGITUDE 80 34 , 13.0000
^ DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS
IZTopographic 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.)
Blue Rido . Tissue _
Facility Name Facility ID# (if applicable)
1427 Yadkin River Road
Street Address
Lenoir NC 28645
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:-21.0'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q/
c. WATER LEVEL Below Top of Casing: 12.0 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 0 FT. Above Land Surface'
`Top of casing terminated aUor 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
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 11.0 Ft. 2" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
: 8. GROUT: Depth Material Method
Top O Bottom 6.0 Ft. Portland Tremie
Top 6.0 Bottom 8.5 Ft. Bentonite Tremie
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 11.0 Bottom 21.0 Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 8.5 _Bottom 21.0 Ft. #1 Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
12. REMARKS:
Formation Description
No samples taken
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I DO HEREBY FY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2 L CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD N PROVIDED TWTHE WELL OWNER.
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Process' Form GW-1b
Rev. 2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] � tit
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