386004_Well Construction - GW1_20100730

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2911A
1. WELL CONTRACTOR.
Gary Skoalund
Well Contractor (Individual) Name
Mad Dawa. Inc.
Well Contractor Company Name
PO Box 398
Street Address
Iron Station
City or Town
(704 ) 732-0213
Area code Phone number
2 WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-1 1
3 WELL USE (Check One Box) Monitoring (1 Municipal/Public ❑
Industrial/Commercial ❑ Agncultural ❑ Recovery ❑ Inlecbon ❑
ImgationD Other ❑ (list use) Pezometer
DATE DRILLED 7/15/10
4 WELL LOCATION:
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code) Top Bottom Ft in In
CITY Charlotte COUNTY Meck Top Bottom Ft in in
TOPOGRAPHIC / LAND SETTING (check appropnate box)
32 004
d. TOP OF CASING IS 0 FT Above Land Surface»
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) N/A METHOD OF TEST
f DISINFECTION. Type N/A Amount
g. WATER ZONES (depth)
Top 23 Bottom 58.5 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING: Depth Diameter Weight Material
Top 0 Bottom 46 5 Ft 1 sch40 pvc
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom 44 5 Ft Portland Tnmmie
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
Seaboard St. Top 48 5 Bottom 58.5 Ft 1 in 010 in pvc
❑Slope ❑Valley hiFlat ❑Ridge ❑Other 10 SAND/GRAVEL PACK:
LATITUDE 35 014 ' 1,490 0000 " DMS OR 3x m0000 xxx DD Top 46 5 Bottom 58 5 Ft 2 pvc
LONGITUDE 80 - 50 ' 2,652 0000 " DMS OR 7X.XXXXXXXXX DD Top Bottom Ft
Latitude/longitude source I,PS Oropographic map Top Bottom Ft
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 11 DRILLING LOG
5. FACILITY (Name of the business where the well is located) Top Bottom Formation Descnption
CSX Railroad
Facility Name
Seaboard St
Street Address
Charlotte
City or Town
Maria Musfeld
Contact Name
500 Water St
Mailing Address
Jacksonville
City or Town
( 904b 633-1517
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 58.5
Depth Size Material
0 / 2 gravel
Facility ID# (if applicable) 2 / 45 sandy silt
45 / 58 5 weathered rock
NC
State Zip Code
FI A 39902
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q/
c. WATER LEVEL Below Top of Casing 23 FT
(Use "+" if Above Top of Casing)
ilk 3 0 2010
/ Information H^�roeesbiiiy
UWQiB33
12. REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS B EN PROVID y' a TH ter" LL 0
7/22/10
SIGNATU FIED WELL . ONTRAC OR DATE
Gary Skoglund
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