385525_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-A
3 WELL USE (Check One Box) Monitoring V Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 5/4/10
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 Flat ❑ 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 11)3PS Qfropographic 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 qI
c WATER LEVEL Below Top of Casing 15.0
(Use "+' if Above Top of Casing)
FT
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 8 0 Ft 2" Sch40 PVC
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 Slot Size Material
Top 8 0 Bottom 18 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 6 0 Bottom 18 0 Ft #1 Sand
Top
Top
Bottom Ft
Bottom Ft
11 DRILLING LOG
Top Bottom Formation Description
8 0 / 12 0' Tan/brown, moist, fine/medium
/ SAND & SILT
14 0 / 18 0 Tan/brown, wet, fine/medium
/ SAND & SILT
/
12 REMARKS
+ 7ntn
JUL 14 l.0 iu
1..,t
InlormatDWCBOG y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C LL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD H , N • ' OVI THE WELL OWNER
S NATURE OF CERTIFIED WELL CONTRACTOR DATE
Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
,,Submitewith lje30idaystof completion to ,Division=ofWater Qualityb- Information3Processing,
1617!Maul ServfceeCenter1'Raleigh, No127699-161; Phone '[phone]
as' „
Form GW-1 b
Rev 2/09

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