411996_Well Construction - GW1_20130304

IVONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
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#(if applicable)
SITE WELL ID #(if applicable) MW-5
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 02/11/13
4. WELL LOCATION:
810 SOUTH COLLEGE ROAD 28403
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WILMINGTON
COUNTY NEW HANOVER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope p Valley Fiat ❑Ridge ❑Other
LATITUDE 34 ° 13 ' 18.4000 "DMS OR DD
LONGITUDE 77 ° 53 ' 4.3000 " DMS OR DD
Latitude/longitude source: VGPS ❑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.)
$2.50 CLEANERS N/A
Facility Name Facility ID# (if applicable)
810 SOUTH COLLEGE ROAD
Street Address
WILMINGTON NC 28403
City or Town State Zip Code
NCDENR
Contact Name
1646 MAIL SERVICE CENTER
Mailing Address
RALEIGH NC 27699
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 15.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO LI
c. WATER LEVEL Below Top of Casing: 4.0 FT.
(Use "+" if Above Top of Casing)
u bm itwithin
617 MailService
completion to:
aleigh, NC 27699-1.
Avq96
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): 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
7. CASING: Depth
Diameter
Top 0.0 Bottom 5.0 Ft. 2 INCH
Top Bottom Ft.
Top Bottom Ft.
Thickness/
Weight Material
SCH 40 PVC
8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. PORTLANDBENTONITE SLURRY
Top Bottom Ft.
: Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 15.0 Ft. 2.0 in. .010 in. PVC
: Top Bottom Ft. in. in.
Top- Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 4.0 Bottom 15.0 Ft. 20-40 FINE SILICA SAND
: Top Bottom Ft.
Top Bottom 'Ft.
11. DRILLING LOG
: Top Bottom
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
0.0 / 1.0
1.0 / 15.0
12. REMARKS:
Size Material
Formation Description
TOPSOIL
GRAY SILTY SAND
F
: BENTONITE SEAL FROM 3.0 TO 4.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE`C�/JTH
15A NCA' 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RE I ' ' HAS BEEN P OVI D "l 0 THE LL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTOR
: VINCE FEDERLE
02/18/13
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ater Quality
19) 807-6300
Form GW-1 b
Rev. 2/09