385501_Well Construction - GW1_20100715

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality 3 L 5 5 0 1i
WELL CONTRACTOR CERTIFICATION # 3544
1 WELL CONTRACTOR
Joshua Ellingworth
Well Contractor (Individual) Name
Parratt-Wolff, Inc
Well Contractor Company Name
501 Millstone Drive
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
Street Address g WATER ZONES (depth)
Hillsborough NC 27278 Top N/A Bottom Top Bottom
City or Town State Zip Code Top Bottom Top Bottom
(919 ) 644-2814 Top Bottom Top Bottom
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 d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 5/18/10
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 Tremie
Top 11 0 Bottom 13 0 Ft Bentonite Tremle
Top Bottom Ft
4 WELL LOCATION 9 SCREEN Depth Diameter Slot Size Material
3301 Monroe Road Top 15 0 Bottom 25 0 Ft 2 in 010 in PVC
(Street Name, Numbers Community Subdivision Lot No Parcel, Zip Code) Top Bottom Ft in in
CITY Charlotte COUNTY Mecklenburg Top Bottom Ft n in
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑Valley hiFlat ❑ Ridge ❑ Other
LATITUDE 35 ° 12 ' 191 0000 " DMS OR 3X XXXXXXXXX DD
LONGITUDE 80 0 48 ' 60000 " 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
Street Address
Charlotte
City or Town
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 & CLAY
Facility ID# (if applicable) /
20 0 / 22 0 Tan/brown, wet, SILT, trace fine/
/ medium sand
NC 28205
State Zip Code
/
Contact Name 1,'
Mailing Address
City or Town
( )
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 25.0'
NI 1 5 2010
rn$arm ,Ei,i .ter „ ,,grrra
State Zip Code 12 REMARKS DWQ/BOG
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO q/
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 L CO STRUCTI • ' TANDARDS AND THAT A COPY OF THIS
ORD - T IDE... • T. WELL OWNER
S ' NATURE OF CERTIF D WELL CONTRACTOR DATE
Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
p �� Form GW-1b
°Submitwithin30'days of�completiorirto:P Division of Water Quality R Information Processing,' Rev 2/09
;1617yMaiI er>vice Center; Raleigh;:NC'27699=161, Phone ~(91`9) 807-6300 4 • -

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