393379_Well Construction - GW1_20110419

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.
Wet 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-6
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(tf applicable)
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED2/24/11
4. WELL LOCATION:
3813 Hwy 74
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wingate COUNTYUnion
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley VVlat ❑ Ridge ❑ Other
LATITUDE 34 0°58 ,55 "DMS DD
LONGITUDE 80 ®° 27.31 "DMS DD
Latitude/longitude source: 12PS [(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.)
Sandy's Cleaners
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: 19
b. DOES WELL REPLACE EXISTING WELI ? YES n NO V
c. WATER LEVEL Below Top of Casing: 11
(Use "+" if Above Top of Casing)
FT.
3 ;.f.:) 7
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 4 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 4 Bottom 19 Ft. 2 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 3 Bottom 19 Ft. Med. Quartz
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 8 Red silty clay
8 / 18 weathered rock
18 / 19 rock
/
/
12. REMARKS:
2011
Infor71ie3boo Pioces4kn.-. e
•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECQRD HAS BEEN PROVIDED TO THE WELL OWNER.
3/4/11
IGN Kt OF CERTIFIED WELL CONTRACTOR DATE
E
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubm'rViithin' 30 bays of completion to Divlslon,of
17 Mall Service Center, Raleigh NC 27699 181, one,.
Form GW-lb
Rev. 2/09