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HomeMy WebLinkAbout398502_Well Construction - GW1_20111004RESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality . ,, • WELL CONTRACTOR CERTIFICATION # 3505 e.) 1. WELL CONTRACTOR: Joe Fornecker Well Contractor (Individual) Name McCaII Bros. 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 1-76 State Zip Code OTHER ASSOCIATED PERMIT#(if applicable) NA SITE WELL ID #(if applicable) NA 3. WELL USE (Check Applicable Box): Residential Water Supply DATE DRILLED 9-6-1 1 J TIME COMPLETED 5:00 AM ID PM II 4. WELL LOCATION: CITY: Waxhaw COUNTY Union 848 Wanderina Wav Dr. Marvin Creek 28175 (Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING: (check appropriate box) ❑Slope ❑Valley dFlat ❑ Ridge ❑Other LATITUDE 35 ° 0 45.5400 " DMS OR 3x.xxxxxxxxx DD LONGITUDE 80 ° 49 16.0700 „ 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. WELL OWNER Eric Root Owner Name 848 Wanderina Wav Dr Street Address Waxhaw City or Town (704 ) 942-0861 Area code Phone number 6. WELL DETAILS: a. TOTAL DEPTH: 320 NC 28175 State Zip Code b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO d c. WATER LEVEL Below Top of Casing: 21 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): 45 METHOD OF TEST air lift f. DISINFECTION: Type HTH Amount 21 OZS g. WATER ZONES (depth): Top 305 Bottom 306 Top NA Bottom NA Top 45 gpm Bottom NA Top NA Bottom NA Top NA Bottom NA Top NA Bottom NA Thickness/ 7. CASING: Depth Diameter Weight Material Top 1 Bottom -39 Ft. 6.125 sch40 PVC Top NA Bottom NA Ft. NA NA NA Top NA Bottom NA Ft. NA NA NA 8. GROUT: Depth Material Method Top 0 Bottom -20 Ft. bentonite pour w.water Top NA Bottom NA Ft. NA NA Top NA Bottom NA Ft. NA NA 9. SCREEN: Depth Diameter Slot Size Material Top NA Bottom NA Ft.NA in. NA in. NA Top NA Bottom NA Ft. NA in. NA in. NA Top NA Bottom NA Ft.NA in. NA in. NA 10. SAND/GRAVEL PACK: Depth Size Material Top NA Bottom NA Ft. NA NA Top NA Bottom NA Ft. NA NA Top NA Bottom NA Ft. NA NA 11. DRILLING LOG Top Bottom 0 / -30 Formation Description Overburden -30 /-320 Gry/wht rock / 12. REMARKS: 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. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE PRINTED NAME OF PERSON CONSTRUCTING THEtWELL►/ !. D Submit within 30 days of completion to: Division of Water Quality - Information Processing, 1617 Mail Service Center, Raleigh, NC'27699-161, Phone : (919) 807-6300 (;I, I f? r 'Ion GW-la Rev. 2/09 CENTRAL FILES DWQ/BOQ