388695_Well Construction - GW1_20101102

NON RESIDENTIAL 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 #(if applicable) MW 17
3 WELL USE (Check One Box) Monitoring Lif Municipal/Public ❑
Industrial/Commercial 0 Agncultural 0 Recovery 0 Injection 0
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)
CITY Charlotte COUNTY Meck
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope EValley WrFlat ❑ Ridge ❑ Other
LATITUDE 35
13 ' 55 4300
" DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 0 36 ' 9 2100 " DMS OR 7X XXXXXXXXX DD
Latitude/longitude source VQPS propographic 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 I eather
Facility Name Facility ID# (if applicable)
15100 Albemarle Rd
Street Address
Charlotte NC 28215
City or Town
Black & Veatch
Contact Name
4210 Metro Parkway Ste 220
Mailing Address
Fort Myers
City or Town
( 239fi 278-3830
Area code Phone number
6 WELL DETAILS.
a TOTAL DEPTH' 38
State Zip Code
FI 33916
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c WATER LEVEL Below Top of Casing 21
(Use "+" if Above Top of Casing)
FT
9 T �k f°
cis
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 DUMP
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 2 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 23 Ft 2 in 20 in PVC
Top 23 Bottom 38 Ft 2 in 10 in PVC
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 3 Bottom 6 Ft #1 Sand
Top 6 Bottom 23 Ft #2 Sand
Top 23 Bottom 38 Ft #1 Sand
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 38 Overburden
12 REMARKS
r irr-o�r�-ee
I\ IL; ter ,9 C !/
N(IV (D 2 LU1U
Information Processing Unit
DWQJBOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO TyE WELL OWNER
StGNATl4RE OF CERTIFIED WELL CONTRACTOR
la-15-10
DATE
Joseph Fornecker
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