385503_Well Construction - GW1_20100715

NONRESIDENTIAL WELL CONSTRUCTION RECORD
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North Carolina Department of Environment and Natural Resources- Division of Water Quality tf
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-E
3 WELL USE (Check One Box) Monitoring INe Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other 0 (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 appropnate box)
❑Slope ❑Valley Q'Flat ❑Ridge ❑Other
LATITUDE 35
° 12 ` 191 0000 " DMS OR 3x xxxxxxXXX DD
LONGITUDE 80 48 6 0000 " DMS OR 7x xxx)000 Xx DD
Latitude/longitude source OGPS fropographic 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 ❑ NO Ni
c WATER LEVEL Below Top of Casing 20.0 FT
(Use "+" if Above Top of Casing)
503
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 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
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 i
20 0 / 22 0 Tan/brown, wet, SILT, trace clav
12 REMARKS
IUl!L 1
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r i1L:'.rSing Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2 ' LL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
RECORD EEN.PKQVIDTHE WELL OWNER
-743/6
S ' NATURE OF CERTfFIED WELL CONTRACTOR DATE
Joshua Ellingworth
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
StubrmYwthin'36,days`of completi n-to Divisign,of-WaterQuality " Information Processing, Form GW-lb
Rev 2/09
1617 Mall Service Center,=Raleigh; C 27699-161, Phone [phone]
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