389971_Well Construction - GW1_20101213

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality 3 :-rr
WELL CONTRACTOR CERTIFICATION # 3505
1 WELL CONTRACTOR
Joe Fornecker
Well Contractor (Individual) Name
McCall Brothers
Well Contractor Company Name
6700 Brookshire Blvd
Street Address
Charlotte NC 28216
City or Town
( 704) 399-1506
Area code Phone number
2 WELL INFORMATION
WELL CONSTRUCTION PERMIT# 10004772
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(if applicable) NA
3 WELL USE (Check Applicable Box) Residential Water Supply 0
DATE DRILLED 11-18-2010
TIME COMPLETED 3:00 AM ❑ PM ll
4 WELL LOCATION
CITY Charlotte COUNTY Meck
Fallina Meadows Lane
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope EValley f, 'Flat ❑ Ridge
LATITUDE 35
0 4 ' 56 0000
(check appropriate box)
❑ Other
" DMS OR 3x XXXXXXXXX DD
LONGITUDE 80 " 58 , 48 7000
Latitude/longitude source I 3PS
(location of well must be shown on a
this form if not using GPS)
5 WELL OWNER
Scott Dayton
" DMS OR 7x XXXXXXXXX DD
❑Topographic map
USGS topo map andattached to
Owner Name
16120 Fallina Meadows Ln
Street Address
Charlotte NC 28273
City or Town State Zip Code
704 ) 962-5727
Area code Phone number
6 WELL DETAILS
a. TOTAL DEPTH 620
b DOES WELL REPLACE EXISTING WELL') YES ❑ NO CAI
c. WATER LEVEL Below Top of Casing 15 FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS 1 .5 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) 25 METHOD OF TEST Air Lift
f DISINFECTION' Type HTH Amount 26 OZS
Top NA
Top NA
g WATER ZONES (depth)
Top 140 Bottom 145
�.;
Top 2 gpm Bottom NA
Top NA Bottom NA Top NA
Top N Bottom NA Top NA
7 CASING. Depth Diameter
Top 1 5 Bottom -26 5 Ft 6 25
Top NA Bottom NA Ft NA
Top NA Bottom NA Ft NA
8 GROUT Depth Material
Top 0 Bottom 20 Ft Bentonite
Top NA Bottom NA Ft NA
Top NA Bottom NA Ft NA
9 SCREEN Depth
Top NA Bottom NA
Top NA Bottom NA
Top NA Bottom N
10 SAND/GRAVEL PACK
Depth
Bottom NA
Bottom NA
Bottom NA
Bottom NA
Thickness/
Weight Material
sch40 PVC
NA NA
NA NA
Method
Pour w water
NA
NA
Diameter Slot Size Material
Ft NA in NA in NA
Ft NA in NA in NA
Ft NA in NA in NA
Size Material
Ft NA NA
Ft NA NA
Top NA Bottom NA Ft NA NA
11 DRILLING LOG
Top Bottom
0 /16
16 /620
12 REMARKS
Formation Descnption
Overburden
Black rock with small white bands
�Po
C 109
tdv`as
Olt, 'vr\o
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTR(JCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
��-1$ 10
S16NATURE 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 -
1617_Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
Form GW-la
Rev 2/09