397318_Well Construction - GW1_20110829

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3298-A
1. WELL CONTRACTOR:
Russell Dve
Well Contractor (Individual) Name
Mad Dawa, Inc.
Well Contractor Company Name
1006 Camp Creek Rd
Street Address
Iron Station NC 28080
City or Town State Zip Code
(704 ) 732-0213
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-1
3. WELL USE (Check One Box) Monitoring tt Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 8-16-11
4. WELL LOCATION:
216 N. Charlotte Ave
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Monroe COUNTY Union
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley 'Fiat ❑ Ridge
LATITUDE 35 ° 5 4.8600
LONGITUDE 80 ° 39 33.1800
❑ Other
" DMS OR 3x.xxxxxxxxx DD
" DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: VGPS [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.)
Family Video
Facility Name Facility ID# (if applicable)
216 N Charlotte
Street Address
Monroe NC. 78112
City or Town State Zip Code
Curtis Helms
Contact Name
9751 Southern Pine Blvd
Mailing Address
Charlotte NC 78273
City or Town State Zip Code
( 704,i 523-4726
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO IV
c. WATER LEVEL Below Top of Casing: 13 FT.
(Use "+" if Above Top of Casing)
397318
d. TOP OF CASING IS 5' FT. Above Land Surface*
"Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A
METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 5 Ft. 2" Sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 3 Ft.
Top 3 Bottom 4 Ft. Bentonite
Top Bottom Ft.
9. SCREEN: Depth
Material
Portland
Method
Tremmie
Pour
Diameter Slot Size Material
Top 5 Bottom 20 Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4 Bottom 20 Ft. #2 Silica
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0 / 20 Orangish Brown Silty Clay
/ A (//; _ r�
/
12. REMARKS:
Inc
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I 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 PROVIDED TO THE WELL OWNER.
Q
SIGNATURE OF CERTIFIED WELL CONTRAOSDJR DATE
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 27699-1.61, Phone (919).807=6300
Form GW-1b
Rev. 2/09