385500_Well Construction - GW1_20100715

NON RESIDENTIAL 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
City or Town
(919 ) 644-2814
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT#
NC
State
27278
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-G
3 WELL USE (Check One Box) Monitoring V Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation Other ❑ (list use)
DATE DRILLED 5/11/10
4 WELL LOCATION
3301 Monroe Road
(Street Name Numbers Community Subdivision Lot No Parcel, Zip Code)
cnTY 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 ' s o000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source ❑GPS Vropographic 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 23.0'
b DOES WELL REPLACE EXISTING WELL" YES ❑ NO qI
c WATER LEVEL Below Top of Casing 19.0 FT
(Use "+" if Above Top of Casing)
tO
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
Top 0 Bottom 4 0 Ft Portland
Method
Tremle
Top 4 0 Bottom 6 0 Ft Bentonite Tremle
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top 8 0 Bottom 23 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 23 0 Ft #1 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Formation Description
5 0 / 9 0' Red/brown, moist, SILT, trace
/ clay
15 0 / 19 0 Gray/white, moist SILT, some
/ clay
19 0 / 23 0 Tan/brown; wet-SIL�T, some clay
Y � R
12 REMARKS
IN 11 I a LOW
InformatLyJC13`cG iii4 ,knit
I DO HEREBY CER
15A NCAC 2C w 1
RECORD HA
THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ONSTRUCTIOTANDARDS AND THAT A COPY OF THIS
ELL OWNER
-7/ / )
SIG • TURE OF CERTIFIED WELL CONTRACTOR DATE
Joshua Eilingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
- Submit within 30°daysyof'corripletion to Dlvlsion-of�Water Quahty� InformatlonsProcessmg,v
1617'Mail Service;Center, Raleigh;4NCt27698 6111111111 PFrone<>[phone]z �a' qY
Form GW-1 b
Rev 2/09

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