385514_Well Construction - GW1_20100715

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
r i
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
Street Address g WATER ZONES (depth)
Hillsborough NC 27278 Top 'N/A Bottom Top Bottom
City or Town State Zip Code Top Bottom Top Bottom
919 ) 644-2814 Top Bottom Top Bottom
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 CI Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 4/27/10
4 WELL LOCATION
10023 North Trvon Street
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
(Street Name, Numbers, Community Subdivision Lot No Parcel Zip Code) Top Bottom Ft in in
cm, Charlotte COUNTY Mecklenburg' Top Bottom Ft in in
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley elat ❑Ridge ❑Other
LATITUDE 35 a 19 • 332 0000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 a 44 • 40 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑GPS (Z(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
10023 North Trvon Street
Facility ID# (if applicable)
Street Address
Charlotte NO 28262
City or Town State Zip Code
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
Formation Description
8 0 / 12 0' Tan/white, moist, medium/coarse
/ SAND & SILT
/
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 IV
c WATER LEVEL Below Top of Casing 13.0
(Use "+" if Above Top of Casing)
FT
12 REMARKS
:1-4;
JUL 1 a� 6 1 %0
ntrormaltan p,
=wilt _ ""Y Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C L CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD H • N ER9VIDED E WELL OWNER
SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
e� Submit witFii 30 mpstd ysofeletionoDiviionofWaoProessing°
,2a 1617`MailService°Center,Raleigh, NC;7699=161;Phne-(9619),8076300j �m
Form GW-1 b
Rev 2/09

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