388693_Well Construction - GW1_20101102

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3505
1 WELL CONTRACTOR
Joseph Fornecker
Well Contractor (Individual) Name
Miller Drilling
Well Contractor Company Name
107 Helton Dr
Street Address
Lawrenceburg
City or Town
(931 ) 762-7548
Area code Phone number
2 WELL INFORMATION.
WELL CONSTRUCTION PERMIT# NA
TN 38464
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(ifapplicable) MW 14A
3 WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agncultural E Recovery E Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10-14-2010
4 WELL LOCATION
15100 Albemarle Rd.
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
cm, Charlotte COUNTY Meck.
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑ Valley Q'Flat ❑ Ridge ❑ Other
" DMS OR 3x xxxxxxxxx DD
" DMS OR 7x xxxxxxxxx DD
LATITUDE 35 0 13 ' 554000
LONGITUDE 80 0 36 ' 101600
Latitude/longitude source WGPS Dropographic 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 )
Ram l eather
Facility Name Facility ID# (if applicable)
15100 Albemarle Rd
Street Address
Charlotte NC 28215
City or Town State Zip Code
Black & Veatch
Contact Name
4210 Metro Parkway Ste 220
Mailing Address
Fort Myers
City or Town
FL 33916
State Zip Code
( 2391 278-3830
Area code Phone number
6. WELL DETAILS
a TOTAL DEPTH 38
b DOES WELL REPLACE EXISTING WELL? YES E NO qI
c WATER LEVEL Below Top of Casing 20 FT
(Use "+" if Above Top of Casing)
Top 3
Top 6
Top
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) <.5 METHOD OF TEST pump
f DISINFECTION Type NA Amount NA
g WATER ZONES (depth)
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Thickness/
7 CASING Depth Diameter Weight Material
Top 0 Bottom 8 Ft 4 sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 3 Ft Cement Pour
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top 8 Bottom 38 Ft 4 in 20 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size
Bottom 6 Ft #1
Material
Sand
Bottom 38 Ft #2 Sand
Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 38 Overburden
/ _ .
12 REMARKS
Information
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
rj1ENORD HAS BEE PRO ED TO THE ELL OWNER
GNAT RE OF CERTIFIED WELL CONTRACTOR
Joseph Fornecker
io-)5- Ic
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone . [phone]
Form GW-1 b
Rev 2/09