388702_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 TN 38464
City or Town State Zip Code
(931 ) 762-7548
Area code Phone number
2 WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NA
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(if applicable) MW 15B
3 WELL USE (Check One Box) Monitoring 11 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation Other ❑ (list use)
DATE DRILLED 10-7-2010
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 grFlat ❑ Ridge ❑Other
LATITUDE 35 0 13 29 5000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 0 36 ' 108000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source VGPS Ofopographic 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 State Zip Code
Black & Veatch
Contact Name
4210 Metro Parkway Ste 220
Mailing Address
Fort Myers FI 33916
City or Town State Zip Code
( 239.6 278-3830
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 38
b DOES WELL REPLACE EXISTING WELL/ YES ❑ NO qI
c WATER LEVEL Below Top of Casing 21
(Use "+" if Above Top of Casing)
FT
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 39 Ft 2 sch40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 3 Bottom 34 Ft Bent Grout Tremie-Pump
Top 34 Bottom 37 Ft Bentonite Pour -Tag
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size Material
Top 39 Bottom 49 Ft 2 in 10 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK
Depth Size Material
Top 37 Bottom 49 Ft #1 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 49 Overburden
/
12 REMARKS
-Unit
Informauol, 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
R: RD HAS B EN PRE ED TO THE, WELL OWNER
711",
SI:NAT RE OF CERTIFIED WELL CONTRACTOR
Joseph Fornecker
(0'1lO
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-lb
Rev 2/09