388706_Well Construction - GW1_20101102

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-�Division of Water Quality
WELL CONTRACTOR CERTIFICATION # J 505
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 16B
3. WELL USE (Check One Box) Monitoring Lill Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
IrrigationE Other ❑ (list use)
DATE DRILLED 10-4-2010
4 WELL LOCATION
15100 Albemarle Rd.
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY Charlotte COUNTY Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑ Slope ❑Valley 'Flat ❑ Ridge ❑ Other
LATITUDE 35 ° 13 558000 " DMS OR 3X XXXXXXXXX DD
LONGITUDE 80 36 10 5000 DMS OR 7x xxxxxxxxx DD
Latitude/longitude source {0: PS [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 State Zip Code
Black & Veatch
Contact Name
4210 Metro Parkway Ste 220
Mailing Address
Fort Myers
City or Town
( 2396 278-3830
Area code Phone number
6 WELL DETAILS
a TOTAL DEPTH 47
FL 33916
State Zip Code
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO al
c WATER LEVEL Below Top of Casing 21 FT
(Use "+" if Above Top of Casing)
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
7 CASING Depth
Top 0 Bottom 37
Top Bottom
Top Bottom
8 GROUT Depth
Top 3 Bottom 32
Top 32 Bottom 35
Top Bottom
Top NA Bottom NA
Top NA Bottom NA
Top NA Bottom NA
Thickness/
Diameter Weight Material
Ft 2 sch40 PVC
Ft
Ft
Material Method
Ft Bent Grout Tremie-Pump
Ft Bentonite Pour -Tag
Ft
9 SCREEN Depth Diameter Slot Size Material
Top 37 Bottom 47 Ft 2 in 10 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10 SAND/GRAVEL PACK
Depth Size Material
Top 35 Bottom 47 Ft #1 Sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Description
0 / 47 Overburden
12 REMARKS
., ‘ o roc># ') fl 1(1
!Vv V `tr e,4 '-
tniOfiiiau�+ �' ' —
vinene[2('1fw
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECAR& 1AS BEEN PROVIDED TO THE WELL OWNER
SIdRN�TUROF CERTIFIED WELL CONTRACTOR
Joseph Fornecker
IC- (S- !o
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-1 b
Rev 2/09