385522_Well Construction - GW1_20100715

NON RESIDENTIAL WELL CONSTRUCTION RECORD 3 GI
North Carolina Department of Environment and Natural Resources- Division of Water Quality t' ey u
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 Nit -applicable) MW-E
3 WELL USE (Check One Box) Monitoring GI Municipal/Public ❑
Industrial/Commercial El Agricultural El Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (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)
ESlope ❑Valley iirFlat ❑ Ridge ElOther
LATITUDE 35 ° 16 ' 443 0000 ° DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 48 - 616 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ['CPS Vlopographic 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 )
Exxon Mobil
Facility Name
1901 Pavilion Boulevard
Facility ID# (if applicable)
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 20.0'
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO qI
c WATER LEVEL Below Top of Casing 15.0 FT
(Use "+" if Above Top of Casing)
d
e
f
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
YIELD (gpm) N/A METHOD OF TEST N/A
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 10 0 Ft 2" Sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom 6 0
Top 6 0 Bottom 8 0
Top Bottom
Material
Ft Portland
Method
Tremle
Ft Bentonite Tremie
Ft
9 SCREEN Depth Diameter
Top 10 0 Bottom 20 0 Ft 2
Top Bottom Ft
Top Bottom Ft
Slot Size Material
in 010 in PVC
in in
in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 8 0 Bottom 20 0 Ft #1 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
80 / 12 0'
160 / 200
12 REMARKS
Formation Description
Red/brown, moist SILT & CLAY,
trace fine/medium sand
Tan/brown, wet SILT, some fine/
medium sand
JUL a 5. 2010
iiiw�es.auv a i r ,.,e
DVVQ/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 HA EN PROVIDEDHE WELL OWNER /
SI 'ATURE OF CERTIFf'ED WELL CONTRACTOR DATE
Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
. Submit wittiin 30gdays of,,completion to Division,of WaterQuality
� .
1617;Maul S ice;CenterRaleigh, NCn27699-161;`Phone' (919)'807=6300
ace# a-ir
Information Processing;
Form GW-1 b
Rev 2/09

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