HomeMy WebLinkAbout385141_Well Construction - GW1_20100625NONRESIDENTIAL 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
(919 ) 644-2814
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-G
3 WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 5/11/10
4 WELL LOCATION
4300 North Graham Street
(Street Name Numbers Community Subdivision Lot No Parcel Zip Code)
CITY Charlotte COUNTY Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley EtFlat ❑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 ❑GPS (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 )
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 WELLS YES ❑ NO qI
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 at/or 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/
Diameter Weight Material
10 0 Ft 2" Sch40 PVC
7 CASING Depth
Top 0 Bottom
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 6 0 Ft Portland Tremie
Top 6 0 Bottom 8 0 Ft Bentonite Tremie
Top
Bottom Ft
9 SCREEN Depth Diameter
Top 10 0 Bottom
Top Bottom
Top Bottom
Slot Size Material
20 0 Ft 2 in 010 in PVC
Ft in in
Ft m in
10 SAND/GRAVEL PACK
Depth Size Material
Top 8 0 Bottom 20 0 Ft #1 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
50 /70'
150 /170
/
/
Formation Description
Red/brown, moist, clayey SILT &
GRAVEL
Tan/brown. wet, SILT & CLAY,
trace fine/medium sand
RECE \r .:
J U N 2 6 2010
12 REMARKS
Information
Processing Una
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C W ' CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS PRO TH ELL OWNER
SIG URE OF CERTIFIED WELL CONTRACTOR DATE
Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit-within-30 days of�completionktol'Division$of=Water-Qualityr- Information Processing,.
1617rMail Service'Center,:iRaleighG 2 N7,699�1617; Phone,a1(9,19) 807-6300g `
-
Form GW-1 b
Rev 2/09
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