385512_Well Construction - GW1_20100715

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3544 3: J 5 5 1 2
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-E
3 WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial D Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 4/26/10
4 WELL LOCATION
10023 North Trvon Street
(Street Name, Numbers, Community Subdivision Lot No Parcel Zip Code)
CITY Charlotte COUNTY Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑ Valley elat ❑ Ridge DOther
LATITUDE 35 0 19 332 0000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 0 44 40 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ['CPS Vtopographic 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)
10023 North Trvon Street
Street Address
Charlotte NC 28262
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 15.0'
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO pi
c WATER LEVEL Below Top of Casing 13.0
(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/
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 5 Ft Portland Tremie
Top 1 5 Bottom 3 0 Ft Bentonite Tremie
Top Bottom Ft
9 SCREEN Depth Diameter
Slot Size Material
Top 5 0 Bottom 15 0 Ft 2 in 010 in PVC
Top
Top
Bottom
Bottom
Ft in m
Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 3 0 Bottom 15 0 Ft #1 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
80 / 12 0'
/
/
12 REMARKS
Formation Description
Tan/white, moist, medium/coarse
SAND & SILT
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JUL i 6 ZUIU
Infairiiaii_i-i r'h)Gz ssing Unit
Ll YY L.,r b L,}t=
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WE - CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS - PRO 0DED TO:R9E WELL OWNER
SIG TURE OF CERTIFIE
—74/c.)
WELL CONTRACTOR DATE
Joshua ElllnQworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
AV - A9 s a y te ster= ,
Suit;w bmithin 30'days of completiori`to., Division of WaterrQu30ality - Information Procin
7 MaiiBg,--
- 161Service Center,�Raleigh, NBC-27699-161,Phone [phone]
Form GW-1 b
Rev 2/09

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