385499_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-D
3 WELL USE (Check One Box) Monitoring Li 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)
crrY Charlotte COUNTY Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑ Valley dFlat ❑ Ridge ❑ Other
LATITUDE 35
12 ' 191 0000 ° DMS OR 3x XXXXXXXXX DD
LONGITUDE 80 48 ' 6 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source FJGPS Q1Topographic 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 28205
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 ❑
c WATER LEVEL Below Top of Casing 20.0
(Use "+" if Above Top of Casing)
NO q/
FT
34
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 15 0 Ft 2" Sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 11 0 Ft Portland
Tremle
Top 11 0 Bottom 13 0 Ft Bentonite Tremle
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
Top 13 0 Bottom 25 0
Top
Top
Bottom
Bottom
Size
Ft #1
Ft
Ft
Material
Sand
11 DRILLING LOG
Top Bottom Formation Description
5 0 / 7 0' Red/brown, moist, SILT, some
/ clay
15 0 / 17 0 Tan/brown, moist clayey SILT
20 0 / 22 0 Tan/brown, wet SILT & CLAY
12 REMARKS
Jr- per,
,
.JUL 1 LU JU
rlWn/ctr ilZ
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2ELL CONSTRU ON STANDARDS AND THAT A COPY OF THIS
ECORD ti 'EE ID HE WELL OWNER
SI ATURE OF CERTIFIED WELL CONTRACTOR DATE
Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
�Subinitw+ntFiin�30`iiays of completion to Division of Water Qualrtyi;AJ fo nation Processing,'
1617`Mail°Service Center, -Raleigh, NC 27699-1'61,-Phone [phone]- am 6300:;;g
Form GW-1 b
Rev 2/09

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