385515_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
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-C
3 WELL USE (Check One Box) Monitoring Nt Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 4/27/10
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 itFlat ❑Ridge ❑Other
LATITUDE 35
19 ' 332 0000 "DMS OR 3X XXXXXXXXX DD
LONGITUDE 80 ° 44 ao 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑GPS gropographic 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 E NO q/
c WATER LEVEL Below Top of Casing 13.0 FT
(Use "+" if Above Top of Casing)
3 55t5
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
Top 0 Bottom 1 5
Top 1 5 Bottom 3 0
Material
Ft Portland
Method
Tremie
Ft Bentonite Tremie
Top Bottom Ft
9 SCREEN Depth Diameter
Top 5 0 Bottom 15 0 Ft 2 in
Top Bottom Ft in
Top Bottom Ft in
Slot Size Material
010 in PVC
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 Formation Description
8 0 / 12 0' Tan/white, moist, medium/coarse
/ SAND & SILT
/ V!C "f—�,�'l�u
/
/
/
12 REMARKS
uL 1 5 2U10
Information I- t.R.233ing Unit
uvvt,titSUL,
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD HAS N PROVIDED TO SHE WELL OWNER
/A)
SIG URE OF CERTIFIED W• ELL CONTRACTOR DATE
oshua Ellingworth
RINTED NAME OF PERSON CONSTRUCTING THE WELL
Submitwithiin 30tdaysof completion_to Divistontof=Water Quality InformationtRrocessing, a
m ®e.�� mow^ a 4.a l`
1617 Mill Service CCe nteer Raleigh, tNC-276 7,161 Phone. "(919),807-630,0
`t °
Form GW-1 b
Rev 2/09

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