392887_Well Construction - GW1_20110401

1 \' ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2511
1. WELL CONTRACTOR:
Ben J. Troxler
Well Contractor (Individual) Name
Troxler Geologic Services, Inc.
Well Contractor Company Name
STREET ADDRESS 1706 Baker Rd.
Raleigh NC 27607
City or Town State
( 919 )_ 828-5252
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
WELL CONSTRUCTION PERMIT#(if applicable)
OTHER ASSOCIATED PERMIT #(if applicable)
3. WELL USE (Check Applicable Box) MonitoringD
Industrial/Commercial❑ Agricultural❑ Recovery0
Irrigation° Other❑ (list use)
Municipal/Public❑
Injection❑
DATE DRILLED 3/23/2011
PMD
Union
TIME COMPLETED 400 AM❑
4. WELL LOCATION:
CITY: Monroe COUNTY
114 Lancaster Ave, Monroe
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
0 Slope 0 Valley 0 Flat 0 Ridge 0 Other
(check appropriate box)
LATITUDE 34.97925
May be in degrees,
minutes, seconds or
in a decimal format
LONGITUDE 80.55088
Latitude/longitude source: 0 GPS 0 Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. FACILITY- is the name of the business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY
STREET ADDRESS 114 Lancaster Ave.
Monroe NC 28112
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS
City or Town State
( )-
Zip Code
YESO NOO
FT.
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 17
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 10ft
(Use "+" if Above Top of Casing)
3 B8f
d. TOP OF CASING IS 0.0 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):
From To From To
From To From To
From To From To
7. CASING: Thickness/
Depth Diameter v�fel ht Mat rial
From 0 To 7 Ft. 2.0 SCfh 40 PVL,
From To Ft.
From To Ft.
8. GROUT: Depth Material Method
From 0 To 2 Ft. Concrete
From 2 To 5 Ft. bentonite
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From 7 To 17 Ft. 2.0 in. 0.01 in. PVC
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
From 5 To 1 7 Ft. #2 Sand
From To Ft.
From To Ft.
11.DRILLING LOG
From To Formation Description
0 0 tan sa silt nfoist at 10ft
ldu silty band w/ gravel
12. REMARKS:
I DO HEREBY C TIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C L CON RUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD H EN PR I ED 1(1.7.44e1RELL OWN
3/29/11
SIGNATURE RTIFIED WELL ONTRACTOR DATE
Ben J. Tr r
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-lb
Rev. 3/07