387574_Well Construction - GW1_20100917

NONRESIDENTIAL 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 Zip Code
( 704 )_ 523-4726
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) MW-7
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring IX Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 8/10/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY Mt Airy
194 Old Lowgap Road
COUNTY Surry
(Street Name, Numbers Community, Subdivision Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley $1 Flat ❑ Ridge 0 Other
(check appropriate box)
LATITUDE 36 32 066' N
LONGITUDE -80 45 713W
Latitude/longitude source
May be in degrees,
minutes, seconds or
in a decimal format
❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
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)
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
( 336 )_ 320-3091
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 50
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO (S(
c WATER LEVEL Below Top of Casing FT
(Use "+" if Above Top of Casing)
33Th74
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/
Depth Diameter Weight Material
From 0 To 30 Ft 2" q 40 PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 To 26 Ft
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 30 To 50 Ft 2 in 010 in PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 26 To 28 Ft #2 Sand
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
31 33 Bentonite
EDE: r%r— A% 7r-- lr,t
N 4,, 't. , %. s +,,.,,., 0 V . kz
SE°1'72010
i n f,-,..t. ,
- `'-' -_olily UPif
11 REMARKS + lit/O/f3%:,'S
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
REO H B E OVIDED 0 THE WELL OWNER
0
8/11/1DATE
SIcGNATU EROF ERTIFIED WELL LLL CONTRACTOR
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-lb
Rev 7/05