385096_Well Construction - GW1_20100712

NooRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2911
1. WELL CONTRACTOR:
Gary Skoalund
Wet Contractor (Individual) Name
Environmental Drilling & Probina Services, LLC
Well Contractor Company Name
17538 Greenhill Road
Street Address
Charlotte NC 28278
City or Town State Zip Code
( 704 ) 607-7529
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NA
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(if applicable) MW-4
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other (list use)
DATE DRILLED 5/14/10
4. WELL LOCATION:
int. of Hwv 601 and Griffin Cemetary Road
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Monroe COUNTY
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley 'Flat 0Ridge ❑Other
LATITUDE 36 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: OGPS OTopographic 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.)
Manaum Family Partnershin
Facility Name Facility ID# (if applicable)
Int of Hwv 601 and Griffin Cemetary Road
Street Address
Monroe 'NC
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 30'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO qI
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
*Top of casing terminated at/or below land surface may rkquirpArl
a variance in accordance with 15A NCAC 2C .Hv
e.. YIELD (gpm): METHOD OF TEST_ HU R
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 15 Bottom 0 Ft. 2 sch.40 PVC
Top Bottom Ft.
Top Bottom Ft.
S. GROUT: Depth
Top 13 Bottom 11
Top 11 Bottom 0
Top Bottom
9. SCREEN: Depth
Top 30 Bottom 15 Ft. 2 in.
Top Bottom Ft. in.
Top Bottom Ft. in.
Material
Ft.. Bentonite
Ft. Grout
Ft.
Method
Tremie
Tremie.
Diameter Slot Size Material
0.01. in. PVC'.
in.
in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 30 Bottom 13 Ft.
Top Bottom Ft.
Top : Bottom Ft.
11. DRILLING LOG
Top Bottom
12. REMARKS:
Formation Description
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DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PRO = • D TO THE WELL OWNER.
SIGNAT . - OF ERTIFIED
LL CONTRACTOR DATE
5/18/10
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]
Form GW-1 b
Rev. 2/09