385518_Well Construction - GW1_20100715

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envttonment 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-B
3 WELL USE (Check One Box) Monitoring IS( Municipal/Public 0
Industrial/Commercial 0 Agricultural ❑ Recovery 0 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)
cm( Charlotte COUNTY Mecklenbure
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley VFlat El Ridge ❑Other
LATITUDE 35 ° 19 3320000 ^ DMS OR 3x XXXXXXXXX DD
LONGITUDE 80 ° 44 , 40 0000
" DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑GPS Vropographic 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 qI
c WATER LEVEL Below Top of Casing 13.0
(Use "+" if Above Top of Casing)
FT
3e' .1
°y er LL"
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
9
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
WATER ZONES (depth)
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 1 5 Ft Portland Tremle
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 Bottom Ft in in
Top Bottom 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 Formation Description
8 0 / 12 0' Tan/white, moist, medium/coarse
/ SAND & SILT
ir^
u� ‘(.�it�illall
/ ,ILJI_ Y 2010
12 REMARKS
tnrormZ.ii0n
O WQ/SQG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C ELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD H.e :EEN •:OVIDEp.3e THE WELL OWNER
/w
S ' NATURE OF CERTIFIED WELL CONTRACTOR DATE
Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit vitltbin 30days`oftcornpletion to Division,of Water`Quahty - Inf rmatign4Processing,
1617 Mail Service'Center, Raleigh„ NG 27699-161, Phone.- [phone]-
Form GW-1 b
Rev 2/09

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Groundwater & Environmental Services, Inc
6655 PEACHTREE DO/MOODY ROAD, SUITE 225 ATIAMA GEORGIA 30328
EXXONMOBIL STATION #4-0583
10023 NORTH TRYON STREET
CHARLOTTE, NORTH CAROLINA
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