385081_Well Construction - GW1_20100701

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3307
1. WELL CONTRACTOR:
Tommy Bolyard
Well Contractor (Individual) Name
Environmental Drilling & Probing 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#
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(ifapplicable) MW-1
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 3/26/10
4. WELL LOCATION:
Int of Hwv 601 & Griffin Cemetery Rd
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Monroe COUNTY lintor)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope 0Valley ❑Flat ❑ Ridge ❑Other
LATITUDE 36 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 75 " DMS OR 7X.XXX)00XXX DD
Latitude/longitude source: DGPS ['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.)
Mannum Family Partnership
Facility Name Facility ID# (if applicable)
Int of Hwv 601& Griffin Cemetery Rd
Street Address
Monroe NC
City or Town
NA
Contact Name
Same
Mailing Address
28420
State Zip Code
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 18'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO LEI'
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 0 FT. Above Land Vr a
*Top of casing terminated at/or below land surface
a variance in accordance with 15A NCAC 2C .0111. ��
e. YIELD (gpm): METHOD OF TEST J,u1.. 1 2Un
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 3 Bottom 0 Ft. 2 sch.40 PVC
Top Bottom Ft.
Top Bottom Ft.
3
508j
8. GROUT: Depth Material Method
Top 2 Bottom 1 Ft. Bentonite Tremie
Top 1 Bottom 0 Ft. Grout Tremie
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 18 Bottom 3 Ft. 2 in. 0.01 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 18 Bottom 2 Ft. #2.med Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
12. REMARKS:
r- oE:'-'ItR
JUL Y 2 201U
Inform::.tinn ';-.,,.c,,...„
T THIS WELL WAS CONS
NSTRUCTION STAN - •-
PROVIDED TO THE fir'
1 C CERTIFY
15A5A NCACCAC 2C,
RECORD HAS
RUCTED IN ACC
ND THAT A
co /•
SIGNATU
F CERTI
ELL
DANCE WITH
F THIS
4/7/10
DATE
To Bolyard
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