387783_Well Construction - GW1_20101008

NON RESIDENTIAL
North Carolina Department of Environment and
WELL CONTRACTOR CERTIFICAT
1 WELL CONTRACTOR
John Hardin
Well Contractor (Individual) Name
Hardin's Pump and Compressor
Well Contractor Company Name
3068 Old Thomasville Road
Street Address
Winston-Salem NC 27107
City or Town State Zip Code
336 ) 769-9128
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-3
3 WELL USE (Check One Box) Monitoring st Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irngation❑ Other ❑ (list use)
DATE DRILLED 9/21/2010
4 WELL LOCATION
1598 C C Camp Road
(Street Name, Numbers, Community, Subdivision, Lot No Parcel Zip Code)
CITY Elkin COUNTY Surry
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope EValley elat ❑ Ridge ❑ Other
LATITUDE 36 16 ' 50 0000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 0 47 • 21 0000
" DMS OR 8x xxxxxxxxx DD
Latitude/longitude source VPS [Topographic 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 )
Elkin Municinal Airport 0-000030
Facility Name Facility ID# (if applicable)
1598 C C Camn Road
Street Address
Flkin NC 28621
City or Town State Zip Code
Town of Elkin
Contact Name
226 N Bridae Street
Mailing Address
Elkin
City or Town
( 336fi 835-9800
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 32'
b DOES WELL REPLACE EXISTING WELL?
NC 28621
State Zip Code
YES ❑ NO q/
c WATER LEVEL Below Top of Casing 29.08 FT
(Use "+" if Above Top of Casing)
WELL CONSTRUCTION RECORD
Natural Resources- Division of Water Quality
ION# 3117-A
d TOP OF CASING IS 0 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) N/A METHOD OF TEST N/A
f DISINFECTION Type N/A Amount
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 12 Ft 2" Sch 41 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 1 Bottom 8 Ft Portland Pour
Top 8 Bottom 10 Ft Bentonite Pour
Top Bottom Ft
9 SCREEN Depth
Diameter Slot Size Material
Top 12 Bottom 32 Ft 2 in 0 01 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size
Top 10 Bottom 32 Ft #3
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0
15
/15
/ 32
12 REMARKS
Material
Filter Sand
Formation Descnption
Orange/CLAY w/ silt. damp
Light orange/. CLAY w/ silt. moist
RECEIVED
OCT 8 2010
Information Processing Unit
DWQ/BOG
0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
CAC 2C ELL CONSTRUCTIO ST • DARDS AND THAT A COPY OF THIS
D HAEEN PROVIDE TO T E ELL OWNER r
PRINTED NAME OF PER
CONTRACTOR
�J -3 7/4-
ON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Divisionwof Water Quality - Information Processing,
1617 Mail Service Center, Raleigh,aiC 27699-161; Phone [phone]', . H -
Form GW-lb
Rev 2/09