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HomeMy WebLinkAbout399547_Well Construction - GW1_201111161170 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 : (919) 807-6300 Information Processing, Form GW-1a Rev. 2/09