383663_Well Construction - GW1_20100101

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3172
1 WELL CONTRACTOR
Everard Baker Jordan
Well Contractor (Individual) Name
Jordan Environmental, LLC
Well Contractor Company Name
68 Little Horse Road
Street Address
Waynesville NC
City or Town State Zip Code
(828 ) 734-2612
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-2
3 WELL USE (Check One Box) Monitonng ri Municipal/Public D
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irngation❑ Other ❑ (list use)
DATE DRILLED 4/9/10
4 WELL LOCATION
204 East State Street. 28711
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
cn-Y Black Mountain
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley vrFlat ❑ Ridge
LATITUDE 35 °
LONGITUDE 82
COUNTY Buncombe
(check appropnate box)
❑Other
" DMs OR 35 619383 DD
" DMS OR 82 318211 DD
Latitude/longitude source BPS Qfopographic 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 )
Roho Chevron Station 0-004164
Facility Name
204 Fast State Street
Street Address
Black Mountain
City or Town
Chin Gould
Contact Name
203 West Kina Street
Mailing Address
Fast Flat Rock
City or Town
Facility ID# (if applicable)
NC 28711
State Zip Code
NC 28762
State Zip Code
( 828fi 697-0501
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 24.0
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c WATER LEVEL Below Top of Casing 11.0 FT
(Use "+" if Above Top of Casing)
3 3 0, 13
d TOP OF CASING IS 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)
28786 Top 11 0 Bottom 24 0 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 0 Bottom 9 0 Ft 2 Sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material
Top 0 0 Bottom 6 0 Ft Portland
Top Bottom Ft
Top Bottom Ft
Method
Tremmie
9 SCREEN Depth Diameter Slot Size Material
Top 9 0 Bottom 24 0 Ft 2 in 10 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 7 0 Bottom 24 0 Ft 2 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
00 /50
5.0
/ 24.0
/
12 REMARKS
Formation Descnption
Dark Bm Silty Sand
Tan Silty Sand
MAY 2 ti 2010
Worn-I:t , rrocessimf:: r �r
I DO HEREBY CERTIFY THAT THIS
RS CAS 8 yL CON�71t2UCTION
R7=C0 EN PR
SIGNATURE CERTIFIED
Everard Baker Jordan
RUCTED IN ACCORDANCE WITH
ND THAT A COPY OF THIS
ER
L CONTRACTOR
4/14/10
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to Division of Water Quality - Information Processing,
TMS
1617 Mail Service Center, Raleigh, NC 27699-161, Phone - [phone] IAN 1 `
GW-1 b
09