398502_Well Construction - GW1_20111004

RESIDENTIAL 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 : [phone]
(;I, I f? r 'Ion GW-la
Rev. 2/09
CENTRAL FILES
DWQ/BOQ