393283_Well Construction - GW1_20110414

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department Of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2675
1. WELL CONTRACTOR:
Robert Miller
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name.
STREET ADDRESS 9088 North Field Dr.
Charlotte N.C.
City or Town State
( )- [phone]
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-2
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box): Residential
DATE DRILLED 4-1-11
Water Supply 0
❑ PM IAA
Union
TIME COMPLETED 1:30 AM
3. WELL LOCATION:
CITY: Monroe COUNTY
Roanoke Church Road @ Hillcrest Church Road
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
l Slope O Valley O Flat O Ridge O Other
(check appropriate box)
LATITUDE 35.05355
May be in degrees.
minutes: seconds or
in decimal format
LONGITUDE 80.54051
Latitude/longitude source: g1GPS ID Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4. WELL OWNER
OWNER'S NAME
STREET ADDRESS
City or Town State
( )-
Zip Code
'
YES O NO'®
FT.
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 18 '
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS D FT. Above
Land Surface*
surface may require
2C .0118.
TEST
*Top of casing terminated at/or below land
a variance in accordance with 15A NCAC
e. YIELD (gpm): METHOD OF
3 3283
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 3' Ft. 2" sch40 pvc
From To Ft.
From To 0 Ft.
7. GROUT: Depth Material Method
From 0 To 1' Ft. Portland pour
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 3' To 18' Ft. 2" in. .010 in. pvc
From To Ft. in. in.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From 2' TO18' Ft. 20/30 silica sand
From To Ft.
From To Ft.
10. DRILLING LOG.
From To Formation Description
0 10' tan silty sand
10' 18' pwr
18'
11. REMARKS: t CFV in
1' bentonite seal from 1' to 2' t'^^'
APR Y 4 2011
inf
_vil
i-'P(, •••,_
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN AC60RDANCEyWITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THA`GAt0I3Y.OF TAIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
4-2-11
--N
SIGNATURE OF CER 1 IFIED 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-la
Rev. 7/05