385502_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-F
3 WELL USE (Check One Box) Monitoring [vl Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 5/17/10
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 ['Walley Flat ❑ 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 ❑GPS Vtopographic 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 Facility ID# (if applicable)
3301 Monroe Road
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 ❑ NO 51
c WATER LEVEL Below Top of Casing 20.0
(Use "+" if Above Top of Casing)
FT
r
v e Q.J iJ
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 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
Size
Ft #1
10 SAND/GRAVEL PACK
Depth
Top 13 0 Bottom 25 0
Top
Top
Bottom
Bottom
11 DRILLING LOG
Top Bottom
Ft
Ft
Material
Sand
Formation Description
50 / 7 0' Red/brown, moist, SILT & CLAY'
15 0 / 17 0 Tan/brown. moist, SILT, trace
/ clay
/
20 0 / 22 0 Tan/brown wet, SILT, trace clay
/ it hia` ( J— Z 'a /I! rN
/ JI II 1 h 2010
12 REMARKS
Information Prucv.:,sing Unit
DVVQ/BUG
I DO HEREBY CE TIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C E L CON TRUCTIO STANDARDS, AND THAT A COPY OF THIS
CORD H B N IDED WELL OWNER
SIG ATURE OF CERTIFIED WELL CONTRACTOR DATE
/Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
-
Submit within30ays• ,of completionRt Di isiotof Water Quality=`informa`tlon Processing
1617 Mad Service Center; Raleigh, NC,27699g161; Rhone [phone], �
m a y • -_� R = _�, s � 4 6 - --- ""*,
Form GW-lb
Rev 2/09

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