384789_Well Construction - GW1_20100623

3
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# N/A
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) VAC-1
3. WELL USE (Check One Box) Monitonng ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agncultural ❑ Recovery ❑ Injection 0
Imgation❑ Other d(list use) SOIL VAPOR
DATE DRILLED 6/9/2010
4. WELL LOCATION:
BAILEY RD. &STARCREEK DR.
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
clrt CORNELIUS COUNTY MECKLENEN
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope [Walley Flat ❑ Ridge ❑Other
LATITUDE 35 ° 27 729 0000 ^ DMS OR 3x XXXXXXXXX DD
LONGITUDE 80 51 268 0000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source 3PS :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 )
FaciIity'Na Facility ID# Of applicable)
BAIT FY RD &STARCRFFK DR
Street Address
CORNFL IUS
City or Town
BRIAN BFI I IS
Contact Name
1410 COMMONWFAI TH DR UNIT 101
NC 28031
State Zip Code
Mailing Address
WII MINGTON NC 98403
City or Town State Zip Code
( 9101 256-9277
Area code Phone number
6 WELL DETAILS:
a TOTAL DEPTH: 20
b DOES WELL REPLACE EXISTING WELL? YES 0 NO q/
c. WATER LEVEL Below Top of Casing N/A FT
(Use °+' if Above Top of Casing)
zp 7 8 9
d TOP OF CASING IS 3 FT Above Land Surface"
'Top of casing terminated at/or below land surface may require
a vanance Inn ccordance with 15A NCAC 2C 0118
e. YIELD (gpm) / "//1 MVT OD OF TEST
f. DISINFECTION: Type Amount
g. WATER NES (depth)
Top I ottom Top Bottom
Top Bottom Top Bottom
Bottom Top Bottom
Thickness/
7 CASING. Depth Diameter Weight Material
Top 0 Bottom 10 Ft 2 " SCH4( PVC
Top
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom 7 Ft PORTLAND TRIMIE
Top Bottom Ft
Top Bottom Ft
9. SCREEN. Depth Diameter Slot Size Material
Top 10 Bottom 20 Ft 2" in 010 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK.
Depth Size Matenal
Top 9 Bottom 20 Ft #2 SAND
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 1' TOPSOIL
1' / 20' FILL
12 REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION S ANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEROVIDED TO T. r' LL OW
6/11/201
SIGNATURE OVi ER d• ELL CONTRA TOR DATE
Gary Skoglund
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
t
Form GW-lb
Submit within 30 days of completion to: Division of Water Quality - Information ProceCEI V 2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] C llF���
JUN2�,)2010
Unit
Information Processing
DWQ/BOG