390606_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 jIndividual) 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-7
NC 28327
State Zip Code
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
IrrigationD Other 0 (list use)
DATE DRILLED12/8/10
4. WELL LOCATION:
8613 Hwy 74
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Marshville COUNTYUnion
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley Vlat ❑ Ridge ❑ Other
LATITUDE 34 0°59 .17 "DMS DD
LONGITUDE 80 O ° 18,59 " DMS DD
Latitude/longitude source: 3PS ['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.)
Watkin's Grocery
Facility Name
see above
Facility ID# (if applicable)
Street Address
see above
NC
City or Town
Kristin Beckwith
State Zip Code
Contact Name
PO Box 16265
Mailing Address
Greensboro
City or Town
(336 ) 335-3174
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 18
NC 27416
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 5 FT.
(Use "+" if Above Top of Casing)
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
Thickness/
7. CASING: Depth Diameter Weight Material
Top -.25 Bottom 3 Ft. 2" Sch 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top .5 Bottom 1 Ft. portland
Top Bottom Ft.
Top Bottom Ft.
Method
tremmie
9. SCREEN: Depth Diameter Slot Size Material
Top 3 Bottom 18 Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 2 Bottom 18 Ft. Med. Quartz
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 /7 ' brown' silty sand
7 / 18 rock
/
/
/
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12. REMARKS:
'' I
•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
1/5/10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
lubmlt,within 30 days of
617 Mail Service Center, R
completion"to Division of Water Qual
tleigh5, NG 276'99 161, Phone [phone]
ormatFon
Form GW-1 b
Rev. 2/09