HomeMy WebLinkAbout410468_Well Construction - GW1_20130211NONRESIDENTIAL WELL CONSTRUCTION RECORD j� ( (p
North Carolina Department of Environment and Natural Resources- Division of Water Quality Il �-
WELL CONTRACTOR CERTIFICATION # /�
1. WELL CONTRACTOR:
.MARK GETTYS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(R applicable)
SITE WELL ID #(ir applicable) GM W-19A
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection 0
Irrigation° Other fgr(list use) GAS PROBE
DATE DRILLED 11/30/12
4. WELL LOCATION:
PINEY GREEN ROAD 28547
(Street Name, Numbers, Community, SubdiWsion, Lot No., Parcel, Zip Code)
CITY: JACKSONVILLE COUNTY ONSLOW
TOPOGRAPHIC / LAND�/SETTING: (check appropriate box)
❑�e FSlope DValley lat 0Ridge ❑Other
LATITUDE 34 ° 41 ' 30.2600 "DMS OR DD
LONGITUDE 77 19 ' 10.3600 " DMS OR DD
Latitude/longitude source: cnps ❑ropographic 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.)
CAMP LEJEUNE N/A
Facility Name Facility ID# (if applicable)
PINEY GREEN ROAD
Street Address
JACKSONVILLE NC 28547
City or Town State Zip Code
CAMP LEJEUNE
Contact Name
PINEY GREEN ROAD
Mailing Address
JACKSONVILLE NC 28547
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 10.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: DRY
(Use "+" if Above Top of Casing)
NO [V
FT.
2345
d. TOP OF CASING IS 2.5 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight
Top 0.0 Bottom 5.0 Ft. 4 INCH SCH 40
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 3.0 Ft. PORRAND BENTONITE
Top Bottom
Top Bottom
Ft.
Ft.
9. SCREEN: Depth Diameter
Top 5.0 Bottom 10.0 Ft. 4.0
Top Bottom Ft.
Top Bottom Ft.
in
inin.
in. in.
Material
PVC
Method
SLURRY
Slot Size Material
•
.010 in. PVC
10. SANDIGRAVEL PACK:
Depth Size Material
Top 4.0 Bottom 10.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 10.0
12. REMARKS:
FINE SILICA SAND
Formation Description
BLACK/TAN/GRAY DRY SAND
u•
O
P tar.
4-N(0,/&fl 3F111S
BENTONITE SEAL FROM 3 0 TO 4 0 FEET
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE yJITFi�,,'."
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF CIS``
RE EEN PR VIDED TO THE WELL OWNER,
SIGNATURE OF CERTIFIED LL CitAtIzN jrniAtEl
MARK GETTYS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit Within 30 daysof completion to Division of.Water Quality Information P,rocessing,
1617 Mail,'Service Center, Raieighr NC 27699-161 Phone :'(919) 807-6,300
Form GW-lb
Rev. 2/09