390605_Well Construction - GW1_20110110

3 cc
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
City or Town
(910 ) 690-6688
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#MW-6
NC 28327
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring VMunicipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection ❑
Irrigation❑ 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 'tat ❑Ridge ❑Other
LATITUDE 34 0°59 ,17 " DMS DD
LONGITUDE 80 ®° 18 ' S9 " 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 NC 27416
City or Town State Zip Code
(336 ) 335-3174
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 18
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO II/
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 Method
Top .5 Bottom 1 Ft. portland tremmie
Top Bottom Ft.
Top Bottom Ft.
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 / 6.5 brown silty sand
6.5 / 18 rock
/
/
/
/
12. REMARKS:
JAN / 02011
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
SIGNAGTURE OF CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within°30 days of completion to 'Divisio'n of Water Quali
1617 Mall Service Center,. Raleigh, NC 27699-161, Phone [phone]
ormation
rocessii
Form GW-lb
Rev. 2/09