385521_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 Ellinaworth
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-F
3 WELL USE (Check One Box) Monitoring 5( Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 5/3/10
4 WELL LOCATION
1901 Pavilion Boulevard
(Street Name, Numbers, Community, Subdivision, Lot No Parcel, Zip Code)
CITY Charlotte COUNTY Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑Valley idFlat ❑ Ridge ❑ Other
LATITUDE 35 ° 16 , 443 0000 "DMS OR 3X XXXXXXXXX DD
LONGITUDE 80 48 ' 616 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source 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)
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 18.0'
b DOES WELL REPLACE EXISTING WELL? YES 0 NO CI
c WATER LEVEL Below Top of Casing 15.0
(Use "+" if Above Top of Casing)
FT
3 55 d1
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 8 0 Ft 2" Sch40 PVC
WATER ZONES (depth)
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 4 0 Ft Portland Tremie
Top 4 0 Bottom 6 0 Ft Bentonite Tremie
Top Bottom Ft
9 SCREEN Depth Diameter
Top 8 0
Top
Top
Bottom 18 0 Ft 2 in
Bottom Ft in
Bottom
10 SAND/GRAVEL PACK
Depth
Top 6 0 Bottom 18 0
Ft
Slot Size Material
010 in PVC
in
in in
Size
Ft #1
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Material
Sand
Formation Description
8 0 / 12 0' Red/brown, moist SILT & CLAY,
/ some fine/medium sand
16 0 / 20 0 Tan/brown, wet SILT, some fine/
/ medium sand
/
.JUL 1 '
Informcniu
12 REMARKS DWO/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 H BEEN PROVIDED TO THE WELL OWNER
SI ATURE OF CERTIFI€D WELL CONTRACTOR DATE
Joshua Eilingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit w'ithin,30,days;offcompletion to•,Division.ofWater Quality== 'Inforrnation;Processing, <
:1617 Mair4ervice ,Cente r2Raletgh, NC 276'99;1�,61', Phoney [phone]
Form GW-1 b
Rev 2/09

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