385142_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 Ellinaworth
Well Contractor (Individual) Name
Parratt-Wolff, Inc
Well Contractor Company Name
501 Millstone Drive
Street Address
Hillsboroubh 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-D
3 WELL USE (Check One Box) Monitoring Ne Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 5/6/10
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 UrFlat ❑Ridge ❑Other
LATITUDE 35 ° 16 ' 4430000
DMS OR 3X XXXXXXXXX DD
LONGITUDE 80 48 ' 616 0000 " DMS OR 7x Xxxxxxxxx DD
Latitude/longitude source ❑PPS (Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 11 DRILLING LOG
5 FACILITY (Name of the business where the well is located) Top Bottom
50 / 90'
3
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/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 5 0 Ft 2" Sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 1 0 Ft Portland Tremie
Top 1 0 Bottom 3 0 Ft Bentonite Tremie
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top 5 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
Top 3 0 Bottom 20 0 Ft #1
Top
Top
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 q�
c WATER LEVEL Below Top of Casing 9 0
(Use "+" if Above Top of Casing)
FT
Bottom Ft
Bottom Ft
90 /130
/
/
/
/
Material
Sand
Formation Description
Tan/brown, moist, SILT &
GRAVEL
Tan/brown, wet, SILT, some clav
REC ! ‘
�� re
/
12 REMARKS
JUN 2 5 201G
InfOfmatton Prcess,ng Unit
DWQ/BO<
I DO HEREBY TIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC W LL CONSTRU ON STANDARDS, AND THAT A COPY OF THIS
CORD 'AS e p2OVI TO THE WELL OWNER
SI NATURE OF CERTIFIED WELL CONTRACTOR DATE
(Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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