NC0006254_Groundwater Monitoring Construction Records (GW1)_20140806

I > NONRESIDENTIAL WELL CONSTRUCTION RECORD
I North Carolina Department of Environment and Natural ReSources- Division of Watcr Quality
" WELL CONTRACTOR CERTIFICATION # 3476
I. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
9088 Northfield Drive
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)_ mw- 6
3. WELL USE (Check One Box) Monitoring 99 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 8-6-14
4. WELL LOCATION:
1427 Yadkin River Road Patterson
(Street Name. Numbers. Community, Subdivision, Lot No., Parcel. Zip Code)
CITY:
COUNTY
TOPOGRAPHIC / LAND SETTING:
(check appropriate box)
❑Slope ❑Valley E]Flat ❑Ridge
001her
LATITUDE
"DMS OR 3X.XXXXXXXXX DD
LONGITUDE
" DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS
E]Topographic 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 welt is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town
State
Zip Code
AECOM
Contact Name
701 Corporate Center Drive
Mailing Address
Raleigh
NC
27607
City or Town
State
.Zip Code
( 919 ) 239-7147
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 27
b. DOES WELL REPLACE EXISTING WELL?
YES ❑
NO M
c. WATER LEVEL Below Top of Casing:
FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 0 FT. Above Land Surface'
`Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
It. DISINFECTION: TypeAmount
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
7. CASING:
Depth
Diameter
Weight
Material
Top 0
Bottom 17
Ft. 2"
40
pvc
= Top
Bottom
Ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material
Method
Top 0
Bottom 13
Ft, portland
pump
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter Slot Size
Material
= Top 17
Bottom 27
Ft. 2" in.
10 in. pvc
Top
Bottom
Ft. in_
in.
Top
Bottom
Ft. in.
in_
10. SANDIGRAVEL PACK:
Depth
Size
Material
Top 15
Bottom 27
Ft. 2
sabd
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom
0
/
27
/
/
/
r
/
/
/
12. REMARKS:
Formation Description
silty cla
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
6/26/2014
Sl i &RTiFIED 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, Form Rev. 2/09/09
1617 Mail Service Center, Raleigh, INC 27699-161, Phone : [phone]

NON RESIDENTIAL WELL CONSTRUCTION RECORD
' r North Carolina Department of Environment and T\aturat Resotuces-Division of\'eater Quality
=" WELL CONTRACTOR CERTIFICATION # 3476
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
9088 Northfield Drive
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) mW-7
3, WELL USE (Check One Box) Monitoring IJ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 8-6-14
4. WELL LOCATION:
1427 Yadkin River Road Patterson
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE " DMS OR 3X.XXXXXXXXX DD
LONGITUDE " DMS OR %X.XXXXXXXXX DID
Latitudellongitude source: ❑GPS ElTopographic 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.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
AECOM
Contact Name
701 Corporate Center Drive
Mailing Address
Raleigh NC 27607
City or Town State Zip Gode
( 919 ) 239-7147
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 24
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO XI
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):
METHOD OF TEST
f. DISINFECTION: Type
Amount
= g. WATER ZONES (depth):
'Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness!
7. CASING: Depth
Diameter Weight Material
Top 0 Bottom 14
Ft. 2" 40 pvc
: Top Bottom
Ft.
Top Bottom
Ft.
:8. GROUT: Depth
Material Method
Top 0 Bottom 10
Ft, portland pvmp
Top Bottom
Ft.
Top Bottom
Ft.
: 9. SCREEN: Depth
Diameter Slot Size Material
Top 14 Bottom 24
Ft. 2" in. 10 in. pvc
Top Bottom
Ft. in. in.
Top Bottom
Ft. in. in.
10. SANDIGRAVEL PACK:
Depth
Size Material
Top 12 Bottom 24
Ft. 2 sabd
= Top Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
0
/
24
/
12. REMARKS:
Formation Description
siltv cla
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.
_ _ 8/26/2014
Sl�fs r CERTI —WELL CONTRACTOR— DATE
c. WATER LEVEL Below Top of Casing: FT Randy Hoffman
(Use "+" if Above Top of Casing)' PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Information Processing, Form 109
Y P tY " g� Rev. 2109
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural RCSOLINCS- Division ofWater Qua] it),
WELL CONTRACTOR CERTIFICATION # 3476
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
9088 Northfield Drive
Street Address
Fort Mill SC 29707
City or Town State Zip Code
{ } _ (803) 548-2,180
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) mw- 8
3. WELL USE (Check One Box) Monitoring pg Municipal/Public ❑
Industrial/Commercial ❑ Agricultural © Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 8-6-14
4. WELL LOCATION:
1427 Yadkin River Road Patterson
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC t LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge L10ther
LATITUDE " DMS OR 3X.XXXXXXXXX DID
LONGITUDE " DMS OR 7X.XXXXXXXXX DID
Latitudellongitude source: BPS ❑]Topographic 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.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
AECOM
Contact Name
701 Corporate Center Drive
Mailing Address
Raleigh NC 27607
City or Town State Zip Code
( 919 ) 239-7147
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO M
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 0
FT. Above Land Surface"
- 'Top of casing terminated
allor 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 Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
7. CASING: Depth
Diameter Weight Material
Top 0 Bottom 10
Ft. 2 40 pvc
Top Bottom
Ft.
Top Bottom
Ft.
• 8. GROUT: Depth
Material Method
Top 0 Bottom 6
Ft. Portland pump
Top Bottom
Ft.
Top Bottom
: 9. SCREEN: Depth
Diameter Slot Size Material
'Top 10 Bottom 20
Ft. 2" in. 10 in. pvc
Top Bottom
Ft. in In.
Top Bottom
Ft. in. m- -.._--
10. SANDIGRAVEL PACK:
Depth
Size Material
:Top 8 Bottom 20
Ft. 2 sabd
Top Bottom
Ft-
Top Bottom
FL
11. DRILLING LOG
Top Bottom
0 1 20
/
t
/
/
/
/
12. REMARKS:
Formation Description
silty c
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-
_ -WE
8/26/2014
SI �IE' 0FRTiiF1 WEWELL CONTRACTOR DATE
Rangy Hoffman
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Form /09
y p ty - Information Processing, Rev. 2109
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]