385498_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-C
3 WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (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 6 0000 " DMS OR 7x XXXXX)IXXX DD
Latitude/longitude source ❑GPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
r
LrJ `
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 15 0 Ft 2" Sch40 PVC
WATER ZONES (depth)
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Material
Top 0 Bottom 11 0 Ft Portland
Top 11 0 Bottom 13 0 Ft Bentonite
Top Bottom Ft
9 SCREEN Depth Diameter
9©
Method
Tremle
Tremle
Slot Size Material
25 0 Ft 2 in 010 in PVC
Top 15 0 Bottom
Top Bottom
Top Bottom
10 SAND/GRAVEL PACK
Depth
Top 13 0 Bottom 25 0
Top
Top
Bottom
Bottom
11 DRILLING LOG
Ft m rn
Ft in in
Size
Ft
Ft
Ft
Material
Sand
5 FACILITY (Name of the business where the well is located) Top Bottom Formation Description
Fxxon Mobil
Facility Name
3301 Monroe Road
Facility ID# (if applicable)
Street Address
Charlotte NC 28205
City or Town State Zip Code
Contact Name
Mailing Address
City or Town
( )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 25.0'
50 /70'
200 / 22 0
/
/
Red/brown, moist, SILT, some
clay
Tan/brown, wet SILT & CLAY
v--R P e
r
JUL 1 2f11Q
Information r'ruc ,Sinn I Init
State Zip Code DWQ/BOG
12 REMARKS
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c WATER LEVEL Below Top of Casing 20.0
(Use "+" if Above Top of Casing)
FT
I DO HEREBY CE IFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C xL CONS UCTIOO TANDARDS AND THAT A COPY OF THIS
ORD H • EN PELL OWNER
SI ATURE OF CERTIFIE
//v
WELL CONTRACTOR DATE
Joshua Ellindworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submitetfiiri,30S
wi1daysi of completion'to Division of Water Quality - Information,Processing,
161�7`Mail Service Center",Raleigh NC�27699-161, Ptione (919)4807-6300 ° '� 4 -,, a
Form GW-1 b
Rev 2/09

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