384782_Well Construction - GW1_20100623

3
NUN RESIDENTIAL 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
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#(rf applicable) N/A
SITE WELL ID #(if applicable) MW-27
3 WELL USE (Check One Box) Monitoring [l Municipal/Public ❑
Industrial/Commercial ❑ Agncultural ❑ Recovery ❑ Injection 0
Imgation❑ Other ❑ (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 MECKLENEN
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley giFlat ❑ Ridge ❑ Other
LATITUDE 35 " 27 ' 713 0000 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 80 " 51 • 324 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 (Name of the business where the well is located )
4-
Facility Name Facility ID# (if applicable)
BAIT FY RD &STARCRFFK DR
Street Address
CORNFLIUS NC 28031
City or Town State Zip Code
BRIAN RFL I IS
Contact Name
1410 COMMONWFAL TH DR UNIT 101
Mailing Address
WII MINCTON NC 28403
City or Town State Zip Code
( 910n 256-9277
Area code Phone number
6 WELL DETAILS:
a. TOTAL DEPTH- 30
b DOES WELL REPLACE EXISTING WELL? YES 0 NO Bit
c. WATER LEVEL Below Top of Casing N/A FT
(Use "+" if Above Top of Casing)
3d4782
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) M/ETnHOD OF TEST
f DISINFECTION: Type /11 / 7 Amount
g. WATER ZONES (depth)
Top ' % Bottom jf Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
Top 0 Bottom 20 Ft
Top Bottom Ft
Top Bottom Ft
Thickness)
Weight Material
SCH4( PVC
8 GROUT Depth Matenai
Top 0 Bottom 16 Ft PORTLAND
Top Bottom Ft
Top Bottom Ft
9. SCREEN- Depth
Top 20 Bottom 30
Top Bottom
Top Bottom
Method
TRIMIE
Diameter Slot Size Material
Ft p" in .010 in PVC
Ft in in
Ft in in
10. SAND/GRAVEL PACK
Depth
Top 18 Bottom 30 Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / 1'
1_/ 20'
20' / 30
12 REMARKS
Size
#2
Material
SAND
Formation Description
TOPSOIL
FILL
RED SANDY SILT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDSEWD THAT COPY OF THIS
RECORD HAS BEEN PROVIDED TO'/THR� WEL
SIGNATURE OF CERTIFI
6/11/201
ELL CONTRACTOR DATE
Gary SkojIund
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]
Form GW-lb
Rev 2/09
RECEIVED
JUN232010
Prnr'essina Unit