381005_Well Construction - GW1_20100225

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Diviston of Water Quality
WELL CONTRACTOR CERTIFICATION # 2394
1 WELL CONTRACTOR
Gerald R Eister
Well Contractor (Individual) Name
Bridger Drilling Enterprises. Inc
Well Contractor Company Name
114 Chimney Lane
3S%65
d TOP OF CASING IS 3" 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
f DISINFECTION Type N/A Amount
Street Address g WATER ZONES (depth)
Wilmington NC 28409 Top Bottom Top Bottom
City or Town State Zip Code Top Bottom Top Bottom
910 ) 799-0493 Top Bottom Top Bottom
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 2/2/10
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 2 Ft 2 sch40 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 1 Ft neat in place
Top Bottom Ft
Top Bottom Ft
4 WELL LOCATION 9 SCREEN Depth Diameter Slot Size Material
5489 NC Highway 50 Top 2 Bottom 10 Ft 2 in 0 10 in pvc
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel Zip Code) Top Bottom Ft in in
CITY Wallace COUNTY DuDIIn Top Bottom Ft in in
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley idFlat ❑Ridge ❑Other 10 SAND/GRAVEL PACK
LATITUDE 34 0 44 . 939 0000 " DMS OR 3x xxxxxxxxx DD DepthMaterial
Size M
Top 1 5 Bottom 12 Ft #2 torpedo
LONGITUDE 77 0 46 . 592 0000 " DMS OR 7x XXXXXXXXX DD
Top Bottom Ft
Latitude/longitude source BPS ❑Topographic map Top Bottom Ft
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 11 DRILLING LOG
5 FACILITY (Name of the business where the well is located) Top Bottom Formation Description
Bahara's Grocery & Grill 0-10 / tan sand
Facility Name Facility ID# (if applicable) 10-12 / arav clay
5489 S NC Rahway 50 /
Street Address /
Wallace NC 28466 /
City or Town State Zip Code /
Doug Haaaett / - i t or --
Contact Name / ` p z LJ
PO Box 15104 /
Mailing Address /
Wilminatan NC 28408
City or Town State Zip Code
( 910n 397-0808
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 12
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Cyr
c WATER LEVEL Below Top of Casing 2 FT
(Use "+" if Above Top of Casing)
12 REMARKS
& 2ui0
iOL>rssmg Unit
DWQ/BOG
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
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SNATURE 0I CERTIFIED WELL CONTRACTOR PATE
0 e . s rot.
PR NTED NAME OF PERSON CONSTRUCTING THE WELL
ems,-
inttr within 30 �laysPtif completion<to: Divistonxiof,WaterrQ IPuahty-- Informat on Processing
1617gMail Service Center, Raleigh, NC 27699-161, Phone [phone]' ",;a 3 tH=M 2
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OCT 2 ; 2013