WI0600071_Well Records_20121010

On1: ,•=�_ NONRESIDENTIAL ��'ELL CONSTREiCT101 RECORD -n~ North Carolina Department of Environment and Natural Resources- Division of Water Quality
'WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9088 Northfield
Fort Mill S.C. 29707
City or Town State Zip Code
80( 3 1- 548-2180
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-4—I
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring M Municipal/Public 0
Industrial/Commercial El Agricultural 0 Recovery L7 Injection rJ
Irrigation❑ Other Ca (list use)
DATE DRILLED 10-10-12
TIME COMPLETED 4 :30 AM ❑ PM zi
3. WELL LOCATION:
'CITY: Laurinburg; COUNTY Scotland
1514 S Main Street
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
El Slope ❑ Valley XI Flat E Ridge L't Other
(check appropriate box)
LATITUDE 34.75834 May be in degrees,
minutes. seconds or
LONGITUDE 79.47203 in a decimal format
L,atitu&-flongitude source: ziGPS ❑Topographic map
(location of weft must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY• is the name of Che business where the well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY one Hour Cleaners
STREET ADDRESS 1514 S Main Street
Laurinburg N.C. 28352
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS Same
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
i
a. TOTAL DEPTH: 4 D
b. DOES WELL REPLACE EXISTING WELL? YES LT NOLCI
c. WATER LEVEL Below Top of Casing: FT.
(Use "+' if Above Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface'
'Top of casing terminated atlor 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
6. CASING: Thickness/ '
Depth Diameter Weight Material
From 30' To 0" Ft. 2" SCH 40 PVC
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 0 T024' Ft. Portland Trimmie
From To Ft.
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 301 TO401 Ft.2 11 in. o10 in. Pvc
From To Ft. in. in.
From To Ft. in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From 28 To 40' Ft #2 Sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 26" Silt/Sand
26' 40' Sand
40' �o,_`
_IN
11. REMARKS: ,r6¢ptnySY1CD prooes51ng
0trt101B0Ca
J #0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN 1` DA'�+11C VV�b
15A. NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT AWs W F f {!IS
REC.ORO HAS BEEN PROVIDED TO THE WELL OWNER 191
SIGNATURE OF CERTIFIED WELL CONTRACTOR AM
Randy Hoffman'
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
116117 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 7105

t ' N®N.RESIDENTIAL WELL CONSTRUCTION RECORD
,.
North Carolina Departmem of Environment and Natural Resources -Division of Water Quality
a t hi /ac
" WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name ,
STREET ADDRESS 908E Northfield
Fort Mill S.C. 29707
City or Town State Zip Code
80( 3 )- 548-2180
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) MW-4-H1B
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ZI MunicipaVPublic ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation[' Other ❑ (list use)
DATE DRILLED 10-10-12
TIME COMPLETED 12 :30 AM ❑ PM W,
3. WELL LOCATION:
CITY: Laurinburg COUNTY Scotland
1514 S Main Street
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: .
[].Slope ❑Valley xi Flat. 13Ridge 0 Other
(check appropriate box)
LATITUDE 34.75834 May be in degrees,
minutes. seconds or
LONGITUDE 79.47203 Ilia decimal lbrinat
Lai itude.1ongitude source: III[ GPS ❑Topographic map
(location of well must be shown on. a USGS topo map and
attached to this form if not using GPS)
4. FACILITY- is the name of Lie business where the we',[ is located.
FACILITY ID #(if applicable)
NAME OF FACILITY one Hour Cleaners
STREET ADDRESS 1514 S Main Street
Laurinburg N.C. 26352
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS Same
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 64'
b. DOES WELL REPLACE EXISTING WELL? YES C NO I
c. WATER LEVEL Below Top of Casing; FT.
(Use "+" if Above Top of Casing)
,�140
101 00
d. TOP OF CASING -IS
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 Tc
6. CASING:
Thickness/
Depth
Diameter Weight Material
From 54' TO 0"
Ft. 2" SCH 40 PVC
From To
Ft. -
From To
Ft.
7. GROUT: Depth
Material Method
From 0 T047'
Ft. Portland Trimmie
From To
Ft.
From To
Ft..
8. SCREEN: Depth
Diameter Slot Size Material
From.54I To64' .
Ftr2" in, olo in. PVC
From To
Ft. in. in.
From To
Ft. in. in.
9. SAND/GRAVEL PACK:
_
Depth -
Size Material
From 521 To 64'
t #2 Sand
Ft.-
From To
Ft.
From To
Ft.
10. DRILLING LOG
From To
Formation Description
0 26"
Silt/Sand
26' 63"
Sand
63' 64'
Clay
6311
7
ii'i
pfl
_._.•��t 1 l�f r
11. REMARKS:
jCgpDriC7at100 prOC SStng�ft
QJ50G
�
T t7
e
I DO HEREBY CERTIFY THAT THIS WELL
WAS CONSTRUCT '-OF
'-O�DRyI��j'lr�
MY
15A NCAC 2C. WELL CONSTRUCTION STANDARCS, hND Tri I Fig l ��jyl1'
RECORD HAS BEEN PROVIDED TO
THE WELL OWNER
� y
nA F#2
SIGNATURE OF CERTIFIED WELL CONTRACTOR E
Randy Hoffman
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-1b
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev. 7105
11