394855_Well Construction - GW1_20110610

NON ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 267s
1. WELL CONTRACTOR:
Robert Miller
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9088 Northfield Dr.
Ft. Mill S.C.
City or Town State Zip Code
( )_ [phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID# (if applicable) MW-8
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring M Municipal/Public 0
Industrial/Commercial O Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 5-17-11
TIME COMPLETED 11:30 AM El PM D
3. WELL LOCATION:
CITY: Marshville
8613 US Highway 74 East
COUNTY Union
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel. Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley Y] Flat ❑Ridge 0 Other
(checkappropriate box)
LATITUDE
LONGITUDE
:Maybe in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑ Topographic map
(location of well must be shown ona USGS topo map and
attached to this form if not using GPS)
4. FACILITY- is the name of the business where the well is located.
FACILITY ID #(ifapplicable)
NAME OF FACILITY Watkins Grocery
STREET ADDRESS 8613 US Highway 74 East
Marshville S.C.
City or Town State
CONTACT PERSON Pyramid. Environmental
Zip Code
MAILING ADDRESS P.0. Box 16265
Greensboro N.C.
27416-0265
City or Town State Zip Code
( 336 )- 335-3174
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20 '
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO El
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
Fr.
3V,t'S55
d. TOP OF CASING IS o 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): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 5' Ft. 2" sch40 pvc
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 To2 ' Ft. port land pour
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 5' Ton ' Ft. 2" ' in. .Olo in. pvc
From To Ft: in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From 3 ' To 20' Ft. 20/30 silica sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 5' pwr
5' 20' Rock
20'
.Er :t—'tV
JliN I 0 Zpi
11. REMARKS: Information prof issirtp One foot bentonite seal from 2' to 3'
DWCJi3ou
1 DO. HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCEWmi.
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT. A. COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
5-18-11
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Robert Miller
PRINTED NAME OF PERSON CONSTRUCTING 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.
Form GW-lb
Rev. 7/05
p
Unit