385139_Well Construction - GW1_20100625

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3544
1 WELL CONTRACTOR
Joshua Ellingworth
Well Contractor (Individual) Name
Parratt-Wolff, Inc
Well Contractor Company Name
501 Millstone Drive
Street Address
Hillsborough NC 27278
City or Town State Zip Code
(919 ) 644-2814
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-E
3 WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 5/10/10
4 WELL LOCATION
4300 North Graham Street
(Street Name, Numbers Community Subdivision Lot No Parcel Zip Code)
ctTY Charlotte COUNTY Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley fgrFlat ❑Ridge ❑Other
LATITUDE 35 ° 16 • 443 0000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 48 616 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑3PS rropographic 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 )
Fxxon Mobil
Facility Name Facility ID# (if applicable)
4300 North Graham Street
Street Address
Charlotte NC 28206
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
( )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 20 0'
b DOES WELL REPLACE EXISTING WELL') YES ❑ NO 57
c WATER LEVEL Below Top of Casing 15 0
(Use "+" if Above Top of Casing)
FT
d TOP OF CASING IS 0 FT Above Land Surface*
*Top of casing terminated ator below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) N/A METHOD OF TEST N/A
f DISINFECTION Type N/A Amount N/A
g WATER ZONES (depth)
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 10 0 Ft 2" Sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 6 0 Ft Portland Tremle
Top 6 0 Bottom 8 0 Ft Bentonite Tremie
Top Bottom Ft
9 SCREEN Depth
Diameter Slot Size Material
Top 10 0 Bottom 20 0 Ft 2 in 010 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 8 0 Bottom 20 0 Ft #1 Sand
Top
Top
Bottom
Bottom
11 DRILLING LOG
Top Bottom
50
/ 7 0'
150
/170
/
/
12 REMARKS
Ft
Ft
Formation Description
Red/brown, moist, silty CLAY,
trace fine/medium sand
Tan/brown, wet, SILT & CLAY,
trace fine/medium sand
%ntormanott Prccossing Unit
DW OG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WEL CONSTRUCTION S NDARDS AND THAT A COPY OF THIS
RECORD HAS BE PROVjpE�T OWNER
SIGNAf7URE OF CERTIFIED
oshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
LL CONTRACTOR DATE
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Form GW-1 b
Rev 2/09

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