390619_Well Construction - GW1_20110110

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3580
1. WELL CONTRACTOR:
Bryan Vest
Well Contractor (Individual) Name
Ransier Environmental Drilling, Inc.
Well Contractor Company Name
1 Piney Point
Street Address
Whispering Pines NC 28327
City or Town State Zip Code
(910 ) 690-6688
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#MW-3
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection ❑
Irrigation❑ Other 0 (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
TOPOGRAPHIC / LAND SETTING:
0Slope ❑ Valley IOW ❑ Ridge
LATITUDE 36 0 017 .32
COUNTYUnion
(check appropriate box)
❑ Other
"DMS
LONGITUDE 80 0 ° 01 ' 09
DD
"DMS DD
Latitude/longitude source: 5PS [(Topographic 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 11/
c. WATER LEVEL Below Top of Casing: 20
(Use "+" if Above Top of Casing)
FT.
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
Thickness/
Weight Material
Top -.25 Bottom 10 Ft. 2" Sch 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top .5 Bottom 6 Ft. portland
Top Bottom Ft.
Top Bottom Ft.
Method
tremmie
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
/
/
/
/
/
12. REMARKS:
Z011
-- . -• _. . ...,
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REC.- D HAS BEEN PROVIDED TO THE WELL OWNER.
1/5/10
SIG T 0 CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit within.'30 days o
617 Matt Service Center,
•
leton to Division of Water Quali
27699 161, Phone [phone].
ormatton Processing,
Form GW-lb
Rev. 2/09