399421_Well Construction - GW1_20111109

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION:##
f.' WELL.CONTRACTOR:"
Michael T. Stanforth
•Well Caitractor (Individual) Name
Excel Civil & Env Assoc
Well Contractor Ccmpany Name
STREET ADDRESS 625 Huntsman Court
Gastonia NC 28054
City; or Town State7
:( 704 y 853-0800
Zip Code
.Area code- Pti'one:number
'2. WELL INFORMATION:
SITE WELL ID #(if,applicable)
STATE WELL PERMIT#(ifapplicable)
DWQ,or. OTHER' P,ERMIT#(if applicable)
'WELL USE (Check Applicable Box)` Monitoring ❑ IMunicipal/Public ❑
Industrial'/Ccmmercial ❑ Agriculturai in -Recoverym Injection ❑
;Irrigatign❑ Other❑ (list,use)-
DATE DRILLED 9/29/11
r P.M D
Union
TIME COMPLETED. 1000 .AM
3. WELL,LOCATION:
.CITY:,, Marshville :COUNTY
8902 Highway 218 East
(Str`eetNaine;'NumberCommunity,:Subdivision, Lot No, -Parcel, Zip code)
TOPOGRAPHIC / LANDISETTING:
❑Slope ❑Valley al Flak ❑ Ridge :❑ Other
(check ;appropriate - box)
LATITUDE 35D 06' 13.2548"
May in degrees,
minutes. seconds or
in a decimal format
LONGITUDE 80D 19' 10.9675"
Latitude/longitude. source; ,oGPS m:Topographic map
,(focation'ofwell must 6eshown on'a'USGS opo map and
attacfied:to`thrs forrrr if not usf) GPS)'.
-4. FACILITY- is thename of me'business where the wet is located.
FACILITY 1D #(if.°applicable)'
NAME OF FACILITY. W.F. Simpson Grocery
STREET ADDRESS 8902 Highway 218 East
Marshville NC
City or Town State Zip Code
CONTACT PERSON Danny Stegall
MAILING ADDRESS Post Office Box 548
Monroe NC 28111
City or Town 'State
( 704 y 283-4517
Zip Code
YES ❑ NO m
N/A FT.
Area case - Phone number
5. WELL DETAILS: SVE-1
a. TOTAL DEPTH: 20'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use "+^ if Above Tcp of Casing)
2525
3421
d. TOP OF -CASING IS - 6" (+/-) _FT..Abave Land Surface*
*Tap of casing terminated,at/or below, land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): - METHOD OF TEST
f. DISINFECTION' Type Amount
-g. WATER ZONES (depth):
From To Fran • To
From To Frcm To
Fran To • From To-
.6. CASING: Thickness/
Depth Diameter Weight Material
Frcm 0' To' 5' Ft: 2" Sch40 PVC
Fran To: Ft.
. Fran To Ft..
7.: GROUT: Depth. Matenal Method
Fran 0' To' 1' 'Ft. Neat Cement Tremmie
From 1' To 3' Ft. Bentonite Tremmie
Frcm To, Ft:-
8. 'SCREEN: Depth Diameter -Slot Size Material
,Frcm 5' To. 20' 'Ft. 2" :in Sch40 in. PVC
Fran To: . Ft. in. , in:
From To, 'Ft. in.. in.
9. SANDI:GRAVEL PACK:
Depth Size Material
'Fran 3' To 20' Ft, #2 Quartz
From To Ft..
Fran To Ft.
16: DRILLING LOG
From To Formation Description
0' 1' Topsoil
1' 8' Orangish brown, stiff clay -sand mixture
8' 20' Dark brown, stiff clay -sand mixture
11. REMARKS;
i.DO HEREBY "CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE VVrn:1
-15A NCAC 2C, WELLCONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO T F +DINER.
9/29/11
. 9/29/11
-SIGNATURE CONTRACTOR DATE
'SI�RE OF
Michael T. Stanforth
PRINTED NAME OF FERIA NAT�I IIN,G�THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 568. NOV 0 9 2011
Form GW-lb
Rev. 7/05
Information Processing Unit
DWQ/BOG