380196_Well Construction - GW1_20100108

01/07/2010 15 58 FAX
ill 001/004
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2630-A
3 0
9Lf
1. WELL CONTRACTOR: g. WATER ZONES (depth)
KENNNETH P. DEROCHE' Top 95 Bottom 119 Top Bottom
Well Contractor (Individual) Name Top Bottom Top Bottom
MEADOWS WELL DRILLING Top Botom Top Bottom
Well Contractor Company Name Thickness/
775 ASHTON LAKE RO, - 7. CASING: Depth diameter Weight Material
Street Address : Top 0 Bottom 99 Ft 2 sch40 pvc
BURGAW NC 28457 Top Bottom Ft
tty or Town State Zip Code Top Bottom Ft.
( 910) 259-5623
Area code Phone number
2. WELL INFORMATION;
WELL CONSTRUCTION PERMIT# 74
OTHER ASSOCIATED PERMff#('dappiccable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ft
DATE DRILLED 12/08/09
TIME COMPLETED 4:00 AM 0 PM
e_ WELL LOCATION:
CITY: Turkey couNTY Duplin
150 POPE WRAY RD, 28393
(Street Name. Numbers, Cosenum iy, Subdivision, Lot No„ Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING' (chedc appropnete box)
❑ Slope ❑Valley 6/1Flat ❑Ridge 0 Other
LATITUDE 35 ° 2 • 33 8300 " DMS OR 3X.AAAX OD
LONGITUDE 78 " a • i7 4458 " OMS OR 7x_Kx.xxxxr{XX OD
Latiludefongltudesource• FitPS fit opographicmap
(location of well must be shown on a USGS topo map andattached to
this form rf not using GPS)
6 WELL OWNER
ARTHUR ELLIOT GARRIS
Owner Name
150 POPE WRAY RD.
Street Address
TURKEY _ _ 1IC 28393
City or Town State Tip Code
(910 ) 284-0959
Area code Phone number
6. WELL DETAILS:
a TOTAL DEPTH: 1 19
b. DOES WELL REPLACE EXISTING WELL? YES gr NO 0
c. WATER LEVEL Below Top of Casing 10 FT
(Use -+" if Above Top of Casing)
d. TOP OF CASING IS 1.5+ FT Above Land Surface"
'Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm)- 25 METHOD OF TEST PUMP
f DISINFECTION: Type hth DQy/der Amount 2 OZ.
Submit within 30 days of completion to: Division of Water Quality -
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
8 GROUT Depth Material
Top 0 Bottom 3 Ft typell cem.
Method
pour
Top 3 Bottom 25 FL well grout DF pressure
Top Bottom Ft.
9. SCREEN: Depth Diameter
Slot Sae Material
Top 99 Bottom 119 Ft2 in .010 In sch40pvc
Top
Top
Bottom _ Ft. on in
Bottom Ft. in. cn.
10. SAND/GRAVEL PACK:
Depth Sirs Material
Top 95 Bottom 119 Ft. 2 sterile silica
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
1 /10
Formation Descnption
top soil & sand
10 / 25 mod. tan sand
25 _ /46 med. tan sand & shell
46 /90 gray soft day
90 /119 coar,$e graili arid_'r"ht.(tti colored san
/
/
12. REMARKS:
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.
1�L>aU' d "- r 12/08/09
SI NATURE OF CERTI ED W0.L CONTRACTOR DATE
KENNETH P. DEROCHE' 1
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
CCTGJ2 3
Information Processing,
Form GW-la
Rev 2/09