384780_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# N/A
NC 28080
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-25
3 WELL USE (Check One Box) Monitonng r1 Municipal/Public ❑
Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection 0
Imgation❑ Other D (list use)
DATE DRILLED 6/9/2010
4. WELL LOCATION-
BAILEY RD. &STARCREEK DR
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zp Code)
CITY CORNELIUS COUNTY MECKLENBI
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley )Flat ❑ Ridge ❑ Other
LATITUDE 35 ° 27 740 0000 " DMS OR 3x XXXXXXXXX DD
LONGITUDE 80 ° 51 ' 280 0000 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source Q3PS ❑topographic map
(locahon 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 )
/11/4
Facility Name Facility ID# (if applicable)
BAIT FY RD &STARCRFFK DR
Street Address
CORNEIIUS NC 28031
City or Town State Zip Code
BRIAN BFI 1 IS
Contact Name
1410 COMMONWFAI TH DR UNIT 101
Mailing Address
WII MINGTON NC 213403
City or Town State Zip Code
( 910,E 256-9277
Area code Phone number
6. WELL DETAILS:
a TOTAL DEPTH: 40
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO rj1
c. WATER LEVEL Below Top of Casing N/A FT
(Use "+" if Above Top of Casing)
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) !i/,4 METHOD OF TEST
f. DISINFECTION: Type /%//4- Amount
g. WATER ZONES (depth)
Top 4 S Bottom / 0 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING Depth Diameter Weight Material
Top 0 Bottom 30 Ft SCH4( PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom_ o Ft PORTLAND TRIMIE
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Material
Top 30 Bottom 40 Ft in .010 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK:
Depth Size
Top 28 Bottom 40 Ft #2
Top Bottom Ft
Top Bottom Ft
Material
SAND
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 1' TOPSOIL
20' FILL
20' / 40 RED SANDY SILT
/
12 REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION ST • i ARDS, AND HAT A COPY.OF THIS
RECORD HAS BEEN. 'rOVIDEDTOTHE l3.'OWN
6/11/201
SIGNATURE OF TIFIED W CONTRACTOR DATE
Gary Skoalund
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Ca
Submit within 30 days of completion to: Division of Water Quality - Information ProcessindRE,CE1 1b
e2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
JUN2i32010
Information Processing Unit
DWQ/BOG