383797_Well Construction - GW1_20100529

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1 WELL CONTRACTOR
Bryan Vest
3 ; re' 9 7
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3580
Well Contractor (Individual) Name
Ransier Environmental Drilling, Inc
Well Contractor Company Name
1 Piney Point
Street Address
Whispering Pines
City or Town
(910 ) 690-6688
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT/PI W-1 R
NC 28327
State Zip Code
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitonng I/Municipal/Public O
Industnal/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irngahon❑ Other 0 (list use)
DATE DRILLED4/26/10
4 WELL LOCATION
1131 NN Ellis Road
(Street Name Numbers Community, Subdivision, Lot No Parcel Zip Code)
CITY Faison COUNTYDupIIn
TOPOGRAPHIC / LAND SETTING (check appropnate box)
El Slope ❑Valley flat ❑Ridge ❑Other
LATITUDE 36 .26 .38 - DMS DD
LONGITUDE 77 " 40 , 57 " DMS DD
Latitude/longitude source OPS Oropographic 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 )
NN Ellis Property
Facility Name
see above
Facility ID# (if applicable)
Street Address
\\, see above
City or Town
Wm Regenthal
NC
State Zip Code
/)/ Contact Name
2301-F Crown Point Executive Dr
Mailing Address
_ Charlotte _ NC 28227
City or Town State Zip Code
7()04 845-4010
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 12'
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO [I
d TOP OF CASING IS - 25 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)
f DISINFECTION Type
g WATER ZONES (depth)
Top Bottom Top
Top Bottom Top
METHOD OF TEST
Amount
Bottom
Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top - 25 Bottom 2 Ft 2" SCh 40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal
Top 5 Bottom 1 Ft portland
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth
Top 2 Bottom 12
Top Bottom
Top Bottom Ft in
Diameter
Ft 2 in
Ft in
Method
tremmle
Slot Size Material
010 in PVC
In
in
10 SAND/GRAVEL PACK
Depth Size Material
Top 2 Bottom 12 Ft Med Quartz
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
/
0 /5
5 /10
10 /12
/
/
/
12 REMARKS
Formation Descnption
MW-1
gravel
brown loose sand
gray silty sand_
NAAY 9 to 'n1n
-y nit
niA!Ci ironr,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCT STANDARDS, AND THAT A COPY OF THIS
RE'.i,-,�' D HASSBEEENPR01Lf8ED T THE WELL OWNER
U1 N 11
c WATER LEVEL Below Top of Casing 4 FT Bryan Vest
(Use "+" if Above Top of Casing)
5/21/10
RTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GVG`l b''F 202