388703_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 10A
3 WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10-6-2010
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 'Flat ❑ Ridge ❑ Other
LATITUDE 35 ° 13 55 3000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 ° 36 9 3000 •• DMS OR 7x xxxxxxxxx DD
Latitude/longitude source UPS ❑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 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
State Zip Code
Mailing Address
Fort Myers FL 33916
City or Town State Zip Code
( 239a 278-3830
Area code Phone number
6 WELL DETAILS*
a TOTAL DEPTH 38
b DOES WELL REPLACE EXISTING WELL? YES D NO qI
c WATER LEVEL Below Top of Casing 22 FT
(Use "+" if Above Top of Casing)
0 `- 1 J
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
Top NA Bottom NA Top NA
7 CASING Depth
Top 0 Bottom 9
Top Bottom
Top Bottom
Bottom NA
Bottom NA
Thickness/
Diameter Weight Material
Ft 2 sch40 PVC
Ft
Ft
8 GROUT Depth Material
Top 3 Bottom 5 Ft Bent Grout
Top Bottom Ft
Top Bottom Ft
9 SCREEN Depth Diameter Slot Size
Top 9 Bottom 24 Ft 2 in 20 in
Top 24 Bottom 39 Ft 2 in 10 in PVC
Top Bottom Ft in in
Method
Tremie-Pump
Material
PVC
10 SAND/GRAVEL PACK
Depth Size Material
Top 5 Bottom 8 Ft #1 Sand
Top 8 Bottom 24 Ft #2 Sand
Top 24 Bottom 39 Ft #1 Sand
11 DRILLING LOG
Top Bottom
0 / 39
/
/
/
12 REMARKS
Formation Descnption
Overburden
0 l4� -rf Ii-,•o I t 171,0
rn nn,n
NUV LUIU
Information et
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RE •RD HAS BE N PROVIDED TO THE WELL OWNER
SI ATU'E 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