388700_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 9A
3 WELL USE (Check One Box) Monitoring V Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10-1 1-2010
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 11Flat ❑ Ridge ❑ Other
LATITUDE 35
° 13 ' 40 6000
LONGITUDE 80 36 9 2000
" DMS OR 3x xxxxxxxxx DD
" DMS OR 7x xxxxxxxxx DD
Latitude/longitude source `QGPS ['Topographic 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 Leather
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
( 239n 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 ❑ NO qI
c WATER LEVEL Below Top of Casing 21
(Use "+" if Above Top of Casing)
FT
3
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 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 Description
0 / 38 Overburden
/
/
(c4 9, 7UIU
-nCSSStag Vie'
/ Inform,'" ;,�0t9OG
12 REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RD HAS BSEN PROy1DED TO THE WELL OWNER
ro-)5-(Q
�18NATURE 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-lb
Rev 2/09