384778_Well Construction - GW1_20100623

3
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma 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
3 E 4778
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) 0 V/A. ETHOD OF TEST
f. DISINFECTION: Type Amount
Street Address g. WATER ZONES (depth)
Iron Station NC 28080 Top 5 6 Bottom J Top
City or Town State Zip Code Top Bottom Top
(704 ) 732-0213 Top Bottom Top
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(ifapplicable) N/A
SITE WELL ID #(if applicable) MW-24
3. WELL USE (Check One Box) Monitonng Nt Municipal/Public ❑
Industrial/Commercial 0 Agncultural 0 Recovery ❑ Injection 0
ImgationD Other 0 (list use)
DATE DRILLED 6/9/2010
4. WELL LOCATION:
BAILEY RD. &STARCREEK DR.
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
Bottom
Bottom
Bottom
Thickness/
7. CASING: Depth Diameter Weight Matenal
Top 0 Bottom 29 Ft i " SCH4( PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal
Top 0 Bottom 25 Ft PORTLAND
Top Bottom Ft
Top Bottom Ft
Method
TRIMIE
9. SCREEN: Depth Diameter Slot Size
Top 29 Bottom 39 Ft in in 010 in
Top Bottom Ft in in
Material
PVC
CITY CORNELIUS couNTY MECKLENBi Top Bottom Ft in in
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley f,IFlat ❑ Ridge ❑ Other
LATITUDE 35 " 27 , 754 0000 "DMS OR 3X XXXXXXXXX DD
LONGITUDE 80 a 51 • 2690000 " DMS OR 7X.XXX)0(XXXX DD
Latitude/longitude source 3PS Dfopographic 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 )
II
Facility" Nam Facility ID# (if applicable)
BAIT FY RD &STARCRFFK DR
Street Address
CORNFI IUS NC 28031
City or Town State Zip Code
BRIAN BFI 1 IS
Contact Name
1410 COMMONWFAI TH DRJJNIT 101
Mailing Address
WII MINGTON NC 2E1403
City or Town State Zip Code
( 9106 256-9277
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 39
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)
10. SAND/GRAVEL PACK:
Depth Size Matenal
Top 27 Bottom 39 Ft #2 SAND
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnpbon
0 / 1' TOPSOIL
1' / 20' FILL
20' / 39' RED SANDY SILT
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12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT • COPY OF THIS
RECORD HAS B _ PROVIDE 0 T LL OW
6/11/201
SIGNATUR :1 'CERTI I s LL CONT- CTOR DATE
Gary Skoglund
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Proce �` �C GW-1b
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
ECE VGe 2/09
Jo232010
Information Processing Unit
DWQ/BOG