384787_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 State
28080
Zip Code
OTHER ASSOCIATED PERMIT#(rf applicable) N/A
SITE WELL ID #(if applicable) VAC-3
3 WELL USE (Check One Box) Monitonng ❑ Municipal/Public 0
Industrial/Commercial ❑ Agncultural ❑ Recovery ❑ Injection ❑
Imgation❑ Other St(Iist 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)
cITY CORNELIUS CouNTY MECKLENhJ
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley elat ❑ Ridge ❑Other
LATITUDE 35 " 27 •724 0000 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 80 ° 51 268 0000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source (BPS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Namepf the business where the well is located )
Facility Name/ Facility ID# (if applicable)
BAIT FY RD &STARCRFFK DR
Street Address
CORNFI IUS NC 2R031
City or Town State Zip Code
BRIAN BFI LIS
Contact Name
1410 COMMQNWFA1 TH DR UNIT 101
Mailing Address
WII MINGTON
City or Town
( 9101 256-9277
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20
NC 2R403
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c WATER LEVEL Below Top of Casing N/A FT
(Use "+" if Above Top of Casing)
3 4787
d. TOP OF CASING IS 3 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) // METHOD OF TEST
f. DISINFECTION: Ty Amount
g WAT
T l_ T,_Bott (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom
Thickness)
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 10 Ft 2 " SCH4( PVC
Top Bottom Ft
Top Bottom Ft
Top
Bottom
8 GROUT Depth Matenal Method
Top 0 Bottom 7 Ft PORTLAND TRIMIE
Top Bottom Ft
- Top Bottom Ft
9. SCREEN: Depth Diameter
Top 10 Bottom 20 Ft 2" in
Top Bottom Ft in
Top Bottom Ft in
10. SAND/GRAVEL PACK:
Depth Size
Top 9 Bottom 20 Ft #2
Top Bottom Ft
Top Bottom Ft
Slot Size Material
010 in PVC
m
in
Material
SAND
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 1' TOPSOIL
20' FILL
12
REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTIO STANDA AND T A COPY OF THIS
RECORD HAS c PRO sEDTO Lam. WE %OWNER
SIGNATUR
6/11/201
ER rl : WELL CON' RACTOR DATE
Gary SkogIund
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]
RECEIVED
JUN 2 3 2010
Information Prnro ,
Form GW-lb
Rev 2/09