385520_Well Construction - GW1_20100715

NON RESIDENTIAL 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-D
3 WELL USE (Check One Box) Monitoring V Municipal/Public E
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection E
Irrigation❑ Other ❑ (list use)
DATE DRILLED 4/30/10
4 WELL LOCATION
1901 Pavilion Boulevard
(Street Name Numbers, Community Subdivision, Lot No , Parcel, Zip Code)
crry Charlotte COUNTY Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other
LATITUDE 35 16 443 0000 "DMS OR 3x XXXXXXXXX DD
LONGITUDE 80 0 48 ' 616 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑PPS Q(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 Facility ID# (if applicable)
1901 Pavilion Boulevard
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 19,0'
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c WATER LEVEL Below Top of Casing 0 FT
(Use "+" if Above Top of Casing)
3v55f;0
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 9 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 7 0 Ft Bentonite Tremie
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top 9 0 Bottom 19 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 7 0 Bottom 19 0 Ft #1 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
50 / 90'
170 / 21 0
/
/
/
12 REMARKS
Formation Description
Red/brown, moist SILT & CLAY
Tan/brown, wet, medium/coarse
SAND & SILT, some gravel
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Infa r,� I In.t
DWQ/BOG
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 t :EEN PROVIDED TO THE WELL OWNER
SI ATURE OF CERTIFIED WELL CONTRACTOR
DATE
Joshua EIIingworth
RINTED NAME OF PERSON CONSTRUCTING THE WELL
SuiVw bmithfin,30,days ocomptetionito' Division of Water4Qualipti Information Processing,
- 1617Maii Service Center, -Raleigh; tjCr27699-161;Phone [phone] -, - - -
Form GW-lb
Rev 2/09

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