384783_Well Construction - GW1_20100623

3
NUN 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 Dawa" Inc.
Well Contractor Company Name
PO Box 398
d. TOP OF CASING IS 3 FT Above Land Surface"
*Top of casing terminated at/or below land surface may require
a vanance in /a .rdance with 15A NCAC 2C 0118
e. YIELD (gpm) V ETHOD OF TEST
f. DISINFECTION: Type Amount
Street Address g. WAT ZONES (debt)
Iron Station NC 28080 Top'; � Bottom 1 Top Bottom
City or Town State Zip Code Top Bottom Top Bottom
(704 ) 732-0213 Top Bottom Top Bottom
Area code Phone number
2 WELL INFORMATION.
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(if applicable) MW-28
3. WELL USE (Check One Box) Monitonng a( Municipal/Public ❑
Industrial/Commercial D Agncultural ❑ Recovery 0 Injection 0
Imgation❑ Other 0 (list use)
DATE DRILLED 6/9/2010
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 21 Ft SCH4( PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal Method
Top 0 Bottom 17 Ft PORTLAND TRIMIE
Top Bottom Ft
Top Bottom Ft
4. WELL LOCATION: 9. SCREEN: Depth Diameter Slot Size Material
BAILEY RD. &STARCREEK DR. Top iteq% Bottom 31 Ft t" in 010 in PVC
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code) Top Bottom Ft in in
cm, CORNELIUS COUNTY MECKLENi Top Bottom Ft in in
TOPOGRAPHIC / LAND SETTING (check appropnate box)
Slope ❑Valley vrFlat ❑Ridge ❑Other 10 SAND/GRAVEL PACK
LATITUDE 35 ° 27 ' 718 0000 " DMS OR 3X XXXXXXXXX DD Depth Size Material
Top gen Bottom 31 Ft #2 SAND
LONGITUDE 80 ° 51 ' 2930000 " DMS OR 7x XXXXXXXXX DD Top Bottom Ft
Latitude/longitude source 3PS Dropographic map Top Bottom Ft
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 11 DRILLING LOG
5. FACILITY (Name of the business where the well is located) Top Bottom Formation Description
/1) /4 0 / 1' TOPSOIL
Facility Na a Facility ID# (if applicable) 1 / 20' FILL
BAIT FY RD &STARCRFFK DR 20' / 31 RED SANDY SILT
Street Address
CORNELIUS NC 28031 /
City or Town State Zip Code /
BRIAN RFI l IS
Contact Name
1410 COMMONWFAI TH DR UNIT 101
Mailing Address
WII MINGTON
City or Town
( 910n1 256-9277
Area code Phone number
6. WELL DETAILS.
a. TOTAL DEPTH: 3
NC 28403
State Zip Code
b DOES WELL REPLACE EXISTING WELL? YES 0 NO 51
c. WATER LEVEL Below Top of Casing N/A FT
(Use "+" if Above Top of Casing)
/
12 REMARKS.
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCT! • STANDAR 1 S, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED T WEL .' WNER
SIGNATUR
6/11/201
ELL CONTRACTOR DATE
Gary Skoglund
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing, Form GW-lb
R
1617 Mail Service Center, Raleigh, NC 27699-161, Phone [phone] ECEIl�J
�`JUN 2 32010
Information Processing Unit
DWQ/BOG