384784_Well Construction - GW1_20100623

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 #(rf applicable) MW-29
3. WELL USE (Check One Box) Monitonng d Municipal/Public ❑
Industrial/Commercial ❑ Agncultural ❑ Recovery ❑ Injection ❑
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)
crry CORNELIUS COUNTY MECKLENRI
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope [Walley 'Flat ❑Ridge ❑Other
LATITUDE 35 " 27 .693 0000 ^ DMS OR 3x.xxxxxxxxx DD
LONGITUDE 80 0 51 318 0000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source 6XPS Dropographic 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 )
P/A
Facility Ndme Facility ID# (if applicable)
BAIT FY RD &STARCRFFK DR
Street Address
CORNFI111S NC 28031
City or Town State Zip Code
BRIAN BFI I IS
Contact Name
1410 COMMONWFAI TH DR UNIT 101
Mailing Address
WII MINGTON NC 78403
City or Town State Zip Code
( 910a 256-9277
Area code Phone number
6. WELL DETAILS'
a. TOTAL DEPTH: 29
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ii
c. WATER LEVEL Below Top of Casing N/A FT
(Use "+" if Above Top of Casing)
384784
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) T METHOD OF TEST
f DISINFECTION: ype 7V/ 4 Amount
g. WATER ZONES (depth)
Top D 7 Bottom "7-. y Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING- Depth Diameter Weight Material
Top 0 Bottom 19 Ft t " SCH4( PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 0 Bottom 15 Ft PORTLAND TRIMIE
Top Bottom Ft
Top Bottom Ft
9. SCREEN: Depth
Top 19 Bottom 29
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK
Depth
Top 17 Bottom 29
Top Bottom
Top Bottom Ft
11 DRILLING LOG
Top Bottom
0 / 1'
1' /20'
20' / 29
12. REMARKS.
Diameter Slot Size Material
Ft t" in 010 in PVC
Ft in m
Ft in in
Size Material
Ft #2 SAND
Ft
Formation Descnption
TOPSOIL
FILL
RED SANDY SILT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTI"N STAND ' DS, AND T A COPY OF THIS
RECORD HAS BEEN PRO'4DED T W OWNE
6/11/201
SIGNATURE O&CERTIFI •i' WELL CON RACTOR DATE
Gary Skoalund
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]
REF EC
.,i
JUN 2 3 2010
Information Processing Uv,
DWQ/BOG