385497_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-B
3 WELL USE (Check One Box) Monitoring [se. Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 5/13/10
4 WELL LOCATION
3301 Monroe Road
(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 ° 12 ' 191 0000 "DMS OR 3x XXXXXXXXX DD
LONGITUDE 80 ° 48 60000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source ❑GPS IXTopographic 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
3301 Monroe Road
Facility ID# (if applicable)
Street Address
Charlotte NC 2_705
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 25.0'
b DOES WELL REPLACE EXISTING WELL, YES ❑ NO 51
c WATER LEVEL Below Top of Casing 20.0
(Use "+" if Above Top of Casing)
FT
97
3��4 t
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
Top
Top
7 CASING Depth Diameter
Top 0 Bottom 15 0 Ft 2"
Top Bottom Ft
Top Bottom Ft
Bottom
Bottom
Bottom
Thickness/
Weight Material
Sch40 PVC
8 GROUT Depth Material Method
Top 0 Bottom 11 0 Ft Portland
Tremie
Top 11 0 Bottom 13 0 Ft Bentonite Tremie
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top 15 0 Bottom 25 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 13 0 Bottom 25 0 Ft #1 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Formation Description
5 0 / 7 0' Red/brown, moist, SILT, some
/ clay
20 0 / 22 0 Tan/brown. wet SILT & CLAY
/
/
/ JUL 1 5 7(11Q
12 REMARKS
,sina Unit
nw0PBGG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C L CONSTRUCTIO STANDARDS AND THAT A COPY OF THIS
RECORD H IDED TIE WELL OWNER
7/1U
SI ATURE OF CERTIFI D WELL CONTRACTOR DATE
Joshua EII►ngworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit uvithin3eilays of completit titb ,D,ivision5of WateriQuallty:-- fInforrnabon,Processmg
'
a1617°Mail Servtce:Center, Raleigh;iNC'27699�=161, Phories,(919)�807=6300y6��
Form GW-1 b
Rev 2/09

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