387573_Well Construction - GW1_20100917

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3350
1 WELL CONTRACTOR
Chad Odom
Well Contractor (Individual) Name
S&ME, Inc
Well Contractor Company Name
STREET ADDRESS 9751 Southern Pine Blvd
Charlotte, NC 28273
City or Town State
( 704 )_ 523-4726
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) MW-6
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring X Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 8/10/10
❑ PM ❑
Surry
TIME COMPLETED AM
3 WELL LOCATION
CITY Mt Airy COUNTY
194 Old Lowgap Road
(Street Name, Numbers Community, Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑Valley X Flat ❑ Ridge 0 Other
(check appropriate box)
LATITUDE 36 32 066' N
May be in degrees,
minutes, seconds or
in a decimal format
-- —
LONGITUDE -80 45 713W
Latitude/longitude source EGPS ❑Topographic
(location of well must be shown on a USGS
attached to this form if not using GPS)
4 FACILITY- is the name of the business where the well is located
FACILITY ID #(if applicable)
map
topo map and
NAME OF FACILITY Eddie Hull Grading
STREET ADDRESS 194 Old Lowgap Road
Mt Airy NC 27030
City or Town State Zip Code
CONTACT PERSON Eddie Hull
MAILING ADDRESS
City or Town State
( 336 )- 320-3091
Zip Code
YES ❑ NO ig
FT
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 55
b DOES WELL REPLACE EXISTING WELL?
c WATER LEVEL Below Top of Casing
(Use "+" if Above Top of Casing)
38 7 5
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)
From To From To
From To From To
From To From To
6 CASING Thickness/
Deptho35 Ft S Diameter Vgi'10t Material
From 0 To
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 To 31 Ft
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 35 To 55 Ft 2 in 010 in PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 33 To �0 Ft #2 Sand
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
31 33 Bentonite
SEP 1 7 2n10
11 REMARKS intormt'ion p,vicessiRg Unit
C.:WQ/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
RECOIZQ HAS BEEN PRQVID TO THEOWNER
C`�!/)�,[/�.fll^l/r11_\l\ 8/11/10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Chad Odom
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn Information Mgt ,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-1b
Rev 7/05