384781_Well Construction - GW1_20100623

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NON RESIDENTIAL 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 Dawo. 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-26
3. WELL USE (Check One Box) Monitonng It1 Municipal/Pubhc ❑
Industrial/Commercial ❑ Agncultural ❑ Recovery 0 Injection ❑
Irngation❑ 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)
CITY CORNELIUS COUNTY MECKLENBII
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ['Walley p'Flat DRidge ❑Other
LATITUDE 35 0 27 ' 734 0000 "DMS OR 3x XXXXXXXXX DD
LONGITUDE 80 0 51 i 309 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source (, 'PS :Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name f the business where the well is located )
Facility Name Facility ID# (if applicable)
BAIT FY RD &STARCRFFK DR
Street Address
CORNFLIUS NC 28031
City or Town State Zip Code
BRIAN BR l IS
Contact Name
1410 COMMONWFAI TH DR UNIT 101
Mailing Address
WII MINGTON
City or Town
( 910{ 256-9277
Area code Phone number
6 WELL DETAILS:
a TOTAL DEPTH. 38
NC 28403
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO r /
c. WATER LEVEL Below Top of Casing N/A
(Use "+" if Above Top of Casing)
FT
d TOP OF CASING IS 3
FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance inaccordance/dawith 15A NCAC 2C 0118
e. YIELD (gpm) /, , v� / METHOD�/jOF TEST
f. DISINFECTION: Type /1///%"' Amount
g. WATER ZONES (depth)
Top 3 5 Bottom 7dr/ Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 28 Ft SCH4( PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom 24 Ft PORTLAND TRIMIE
Top Bottom Ft
Top Bottom Ft
9. SCREEN' Depth Diameter Slot Size Material
Top 28 Bottom 38 FtI"_m 010 in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK:
Depth Size
Top 26 Bottom 38 Ft #2
Top Bottom Ft
Top Bottom Ft
Material
SAND
11 DRILLING LOG
Top Bottom Formation Descnption
0 / 1' TOPSOIL
1' / 20' FILL
20' / 38 RED SANDY SILT
12 REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTI•N STANDARDS, AND T I. COPY OF THIS
RECORD HAS BE PROVIDED T• Tr WELL •- NER
6/11/201
SIGRATURE 'CE-TIFI f ELL CONTRA OR DATE
Gary SkociIund
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Process
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] E `r" E 1\/
W-1 b
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JUN 2 3 2010
Information Processing Unit
DWQ/BOG