399547_Well Construction - GW1_20111116

1170 33673
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3505
1. WELL CONTRACTOR:
Joe Fornecker
Well Contractor (Individual) Name
McCall Brothers
Well Contractor Company Name
6700 Brookshire Blvd
Street Address
Charlotte NC 28216
City or Town
( 704) 399-1506
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# 1 1-122
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID #(if applicable) NA
3. WELL USE (Check Applicable Box): Residential Water Supply Mf
DATE DRILLED 9-20-1 1 J
TIME COMPLETED 3:00 AM 0 PM Iv
4. WELL LOCATION:
CITY: Waxhaw COUNTY Union
423 Oakmont Ln. Lonaview. 28173
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley El Flat gTRidge ❑Other
LATITUDE 35 ° 1 • 27.3900 "DMS OR 3X.XXXXXXXXX DD
LONGITUDE 80 ° 47 , 6.8200 " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: IVGPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Doualas Chen
Owner Name
423 Oakmont Lane
Street Address
Waxhaw NC 28173
City or Town State Zip Code
(704 ) 622-7109
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 900
b. DOES WELL REPLACE EXISTING WELL? YES ❑
NO d
c. WATER LEVEL Below Top of Casing: 31 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 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): 10 METHOD OF TEST Air Lift
f. DISINFECTION: Type HTH Amount 30 oZs
Top NA
Top NA
Top NA
g. WATER ZONES (depth):
Top 650 Bottom 4 gpm
Top 850 Bottom 6 gpm
Top NA
399547
Bottom NA
Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
7. CASING: Depth
Top 1 Bottom -46
Top NA
Top NA
Bottom NA
Bottom NA
Thickness/
Diameter Weight Material
Ft.6.125 sch40 PVC
Ft. NA NA NA
Ft. NA NA NA
8. GROUT: Depth Material
Top 0 Bottom -20 Ft. bentonite
Top NA Bottom NA Ft. NA
Top NA Bottom NA Ft. NA
9. SCREEN: Depth Diameter Slot Size
Top NA Bottom NA Ft.NA
Ft. NA in. NA in. NA
Ft. NA
Top NA Bottom NA
Top NA Bottom NA
10. SAND/GRAVEL PACK:
Depth
Bottom NA
Method
pour w.water
NA
NA
Material
in. NA in. NA
in. NA in. NA
Size Material
Ft. NA NA
Bottom NA Ft. NA NA
Bottom NA Ft. NA NA
11. DRILLING LOG
Top
0
Bottom
/40
40 /900
12. REMARKS:
Formation Description
Overburden
Grey rock
RECEIVED
NOVG 2011
Information Processing sing Unit
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
PRO IDED TO THE WELL OWNER.
9Z2i'
SI" ATURE OF CERTIFIED WELL CONTRACTOR DATE
Job. For ecker
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
Form GW-1a
Rev. 2/09