390618_Well Construction - GW1_20110110

NON RESIDENTIAL
North Carolina Department of Environment and
WELL CONTRACTOR CERTIFICAT
1. WELL CONTRACTOR:
Bryan Vest
Well Contractor (Individual) Name
Ransier Environmental Drilling, Inc.
Well Contractor Company Name
1 Piney Point
Street Address
Whispering Pines
City or Town
910 ) 690-6688
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#MW-2
NC 28327
State Zip Code
OTHER ASSOCIATED PERMIT#{ifapplicable)
SITE WELL ID #(ifapplicable)
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection ❑
Irrigation0 Other ❑ (list use)
DATE DRILLED12/6/10
4. WELL LOCATION:
3615 Hwy 74 East
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wingate
COUNTYUnion
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley flat ❑ Ridge ❑ Other
LATITUDE 36 0 .17 .32 " DMS
LONGITUDE 80 0 0 01 , 09 "DMS
DD
DD
Latitude/longitude source: 3PS DTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Wingate Valero
Facility Name
see above
Facility ID# (if applicable)
Street Address
see above
NC
City or Town
Laura Minor
State Zip Code
Contact Name
410 E. Franklin Street
Mailing Address
Monroe NC 28112
City or Town State Zip Code
( 704 ) 289-5881
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 35
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO i)!I
c. WATER LEVEL Below Top of Casing: 20
(Use "+" if Above Top of Casing)
FT.
WELL CONSTRUCTION RECORD
Natural Resources- Division of Water Quality
ION # 3580
d. TOP OF CASING IS -.25 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):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter
Top -.25 Bottom 10 Ft. 2"
Top Bottom Ft.
Top Bottom Ft.
Thickness/
Weight Material
Sch 40 PVC
8. GROUT: Depth Material Method
Top .5 Bottom 6 Ft. portland tremmie
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 10 Bottom 35 Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 8 Bottom 35 Ft. Med. Quartz
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 12 brown silty clay
12 /35 rock
/
+ _ r
./ .IAN 110011
/
/
12. REMARKS:
inici:,.r::rtl i-arcC O:i,r j UM(
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RE HAS BEEN PROVIDED TA THE WELL OWNER.
1/5/10
SIGN/(TURE OF CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
s;.
bmit within' 30 days of completion to Division of Water Quality;
I7 Mail Service Center, Raleigh, NC 27699 '161, Phone [phone].
Form GW-lb
Rev. 2/09