388704_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
c-
c;
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 DU MD
f DISINFECTION Type NA Amount
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 1 6A
3 WELL USE (Check One Box) Monitoring LEI Municipal/Public ❑
Industrial/Commercial 0 Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10-6-2010
Top NA Bottom NA
Top NA Bottom NA
Top NA
Top NA
NA
Bottom NA
Bottom NA
Bottom NA
Thickness/
7 CASING Depth Diameter Weight
Top 0 Bottom 17 Ft 2
Top Bottom Ft
Top Bottom Ft
Material
sch40 PVC
8 GROUT Depth Material
Top 3 Bottom 13 Ft Bent Grout
Top Bottom Ft
Top Bottom Ft
Method
Tremle-Pump
4 WELL LOCATION 9 SCREEN Depth Diameter Slot Size
15100 Albemarle Rd. Top 17 Bottom 27 Ft 2 in 20 in
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code) Top 27 Bottom 37 Ft 2 in 10 in PVC
CITY Charlotte COUNTY Meck Top Bottom Ft in in
Material
PVC
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley hiFlat ❑Ridge ❑Other
LATITUDE 35 ° 13 55 3000 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 ° 36 10 9000 " 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 l eather
Facility Name Facility ID# (if applicable)
15100 Albemarle Rd
Street Address
Charlotte NC 26216
City or Town State Zip Code
Black & Veatch
Contact Name
4210 Metro Parkway Ste 220
Mailing Address
Fort Myers FL 33916
City or Town State Zip Code
( 23910 278-3830
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 38
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO 51
c WATER LEVEL Below Top of Casing 20 FT
(Use "+" if Above Top of Casing)
10 SAND/GRAVEL PACK
Depth Size
Top 13 Bottom 15 Ft #1
Material
Sand
Top 15 Bottom 27 Ft #2 Sand
Top 27 Bottom 38 Ft #1 Sand
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 38 Overburden
12 REMARKS.
I`In\V 0 2 NW
Information wIng unit
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 HAS BEEN PROVIDED TO THE WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR
Joseph Fornecker
/0-15-10
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