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HomeMy WebLinkAbout391926_Well Construction - GW1_20110419NONRESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # 1. WELL CONTRACTOR: Bryan Vest Well Contractor (Individual) Name Ransier Environmental Drilling Well Contractor Company Name PO Box 923 Street Address Pinehurst NC 28370 City or Town State Zip Code ( ) Area code Phone number 2. WELL INFORMATION: WELL CONSTRUCTION PERMIT# OTHER ASSOCIATED PERMIT#(if applicable) SITE WELL ID #(ifapplicable)MW3 3. WELL USE (Check One Box) Monitoring VMunicipal/Public ❑ Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection 0 Irrigation❑ Other 0 (list use) DATE DRILLED11 /16/10 4. WELL LOCATION: 9911 Olive Branch Rd. (Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) CITY: Marshville COUNTYUnIOn TOPOGRAPHIC / LAND SETTING: (check appropriate box) ❑Slope ❑Valley ❑ Flat ❑ Ridge ❑Other LATITUDE 36 ®° "DMS LONGITUDE 75 ® ° " DMS 35.103307 80.320726 DD DD Latitude/longitude source: ❑GPS [(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.) Fred Staton's Store Facility Name 9911 Olive Branch Rd. Facility ID# (if applicable) Street Address Marshville NC 28103 City or Town State Zip Code State Lead Program Contact Name 1637 Mail Service Center Mailing Address Raleigh City or Town NC 27699 State Zip Code ( ) Area code Phone number 6. WELL DETAILS: a. TOTAL DEPTH: 25' b. DOES WELL REPLACE EXISTING WELL? YES 0 NO E/ c. WATER LEVEL Below Top of Casing: FT. (Use "+" if Above Top of Casing) d. TOP OF CASING IS 0 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 0 Bottom 5' Ft. 2 in. sch 40 PVC Top Bottom Ft. Top Bottom Ft. 8. GROUT: Depth Material Method Top 0 Bottom 3' Ft. Portland Pour Top 3' Bottom 4' Ft. Bentonite Pour Top Bottom Ft. 9. SCREEN: Depth Diameter Slot Size Material Top 5' Bottom 25' Ft. tin in. .010 in. PVC Top Bottom Ft. in. in. Top Bottom Ft. in. in. 10. SAND/GRAVEL PACK: Depth Size Material Top 4' Bottom 25' Ft. coarse Sand Top Bottom Ft. Top Bottom Ft. 11. DRILLING LOG Top Bottom Formation Description 0 / 1' GRAVEL 1' /6' MUDSTONE 6' / 25' BEDROCK / / / I ,6^ a 117 It / [iii P. 1 b 7011 12. REMARKS: Infnrmati. fe, r., .. .. ,.flO Unit DWC: TOG 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. 11 /17/10 SIGNURE OF CERTIFIED WELL CONTRACTOR DATE Bryan Vest PRINTED NAME OF PERSON CONSTRUCTING THE WELL bmit within 30ndays of completion to 7 Mall Service Center, Raleigh, NC 27699 one lateti Quali; 919),807 63. ormationProcessin Form GW-1 b Rev. 2/09