388696_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
f'
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)
TN 38464 Top NA Bottom NA Top NA
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(if applicable) MW 14B
3 WELL USE (Check One Box) Monitoring C1 Municipal/Public ❑
Industrial/Commercial E Agricultural E Recovery E Injection ❑
IrrigationE Other ❑ (list use)
DATE DRILLED 10-13-2010
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 ❑Valley elat ❑ Ridge ❑Other
LATITUDE 35
°13 . 55 2100
" DMS OR 3X XXXXXXXXX DD
LONGITUDE 80 36 10 0700 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source Qj3PS ETopographic 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
15100 Albemarle Rd
Facility ID# (if applicable)
Street Address
Charlotte NC 28215
City or Town
Black & Veatch
Contact Name
4210 Metro Parkway Ste 220
State Zip Code
Mailing Address
Fort Myers
City or Town
( 23911 278-3830
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 38
FL 33916
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES E NO p�
c WATER LEVEL Below Top of Casing 20
(Use "+" if Above Top of Casing)
FT
Top NA Bottom NA Top NA
Top NA
Bottom NA Top NA
Bottom NA
Bottom NA
Bottom NA
Thickness/
7 CASING Depth Diameter Weight
Top 0 Bottom 38 Ft 4
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth
Top 0 Bottom
Top 3 Bottom
Top 33 Bottom
Material
sch40 PVC
Material
3 Ft Cement
33 Ft Bent Grout
36 Ft Bentonite
Method
Pour
Tremle-Pump
Pour -Tag
9 SCREEN Depth Diameter Slot Size Material
Top 38 Bottom 48 Ft 4 in 20 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size
Top 36 Bottom 48 Ft #2
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / 48
12 REMARKS
Material
Sand
Formation Descnption
Overburden
in Riff7(! i
M(lt/ I 0 'min
�• �+ LUiu
Information Prnr,acc,nn i Ina.
DWQ/BOG
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 THE WELL OWNER
IQ -/s-- (c
NATURE OF CERTIFIED WELL CONTRACTOR 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