386809_Well Construction - GW1_20100101

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3367
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
(919 ) 644-2814
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) RW-1
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery L'Inlection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 8/9-8/10/10
4 WELL LOCATION
622 New Airport Road
(Street Name Numbers Community, Subdivision Lot No Parcel Zip Code)
CITY Arden COUNTY Buncombe
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley Fiat ❑Ridge ❑Other
LATITUDE 35 ° 26 ' 337 0000 "DMS OR 3X XXXXXXXXX DD
LONGITUDE 82 32 208 0000 ° DMS OR 7x XXXXXXXXX DD
Latitude/longitude source ❑GPS Vropographic 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 )
Fxxon Mobil
Facility Name Facility ID# (if applicable)
622 New Airport Road
Street Address
Arden NC 28704
City or Town State Zip Code
Contact Name
Mailing Address
City or Town
( )
Area code Phone number
6 WELL DETAILS
State Zip Code
a TOTAL DEPTH 55.0'
b DOES WELL REPLACE EXISTING WELL/ YES Di NO ❑
c WATER LEVEL Below Top of Casing 45.0 FT
(Use "+" if Above Top of Casing)
386809
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 35 0 Ft 6" Sch40 PVC
Top_ Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 Bottom 31 0 Ft Portland
Top 31 0 Bottom 33 0 Ft Bentonite
Top Bottom Ft
9 SCREEN Depth Diameter
Top 35 0 Bottom 55 0 Ft 6
Top Bottom Ft
Top Bottom Ft
Method
PVC
PVC
Slot Size Material
in 010 in PVC
in in
in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 33 0 Bottom 55 0 Ft #1 and !P'-
Top Bottom Ft , 1 Imo- D
Top Bottom Ft 013
!r i, 7 2010
11 DRILLING LOG
Top Bottom FormgtiorrD ;tpt dowsing Unit
/ No samples tg RiB°G
/
12 REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2ELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORDH EEN PRfa*119ED TO THE WELL OWNER
SIGN OF CERTIFIE
Ga Ilingwortti'
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
xe F -kB a ° c w ,� 14 Op
.a a 'f� '�s P °ee°'� ��a
sSub • nit-0within 30�daystotcompletion to 3Division'of.Watei uality - Infonnation1
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e 16174Mail Service Center 92aleigh,-NC127699 ,161;Phone� .(819)°807 6300 � 1,
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WELL CONTRACTOR , DAT
Form GW-lb
Rev 2/09

eW5
-GRASS-
-GRASS-
9Mw6
[RW-1
LEGEND
FORMER USED OIL TANK
( ) DISPENSER ISLAND
® CATCH BASIN
UTILITY POLE
® OBSERVATION POINT
MONITORING WELL
CD AIR SPARGC/SOIL VAPOR EXTRACTION POINT
- U- - UNDERGROUND ELECTRIC LINE
- w -- UNDERGROUND WATER LINE
---- OVERHEAD ELECTRIC LINE
DRMRED BY
DMK
(NJ)
CN_CKED BY
PG
REWER_D BY
PM
SITE MAP
EXXONMOBIL REFINING & SUPPLY COMPANY
EXXON SERVICE STATION #4-5173
622 NEW AIRPORT ROAD
FLETCHER, NORTH CAROLINA
NORTH Groundwater & Environmental Services, Inc
3344 HILLSBOROUGH STREET SURE I50 RALEIGH NORTH CAROUNA 27607
11) SCALE IN FOOT DATE FIGURE
APPROXIMATE
11-2-07 2
0 40