411995_Well Construction - GW1_20130304

Z%TONRESIDENTIAL WELL CONSTRUCTION RECO
RD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address ; g. WATER ZONES (depth):
3552
STATESVILLE NC 28625 Top Bottom
City or Town ; Top Bottom
State Zip Code Top Bottom TopBottom
ottom
Top . Bottom Top Bottom
9 5
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
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW'4
( 704 ) 872-7686
Area code Phone number
2. WELL INFORMATION: iThickness/
7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# : Top 0.0 Bottom 5.0 Ft. 2 INCH SCH 40 PVC
: Top Bottom Ft.
: Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring /Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection ❑
Irrigation Other ❑ (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)
CI-TY: WILMINGTON COUNTY NEW HANOVER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Walley elat ❑ Ridge DOther
LATITUDE 34 ° 13 ' 16.7800 DMS OR DD
LONGITUDE 77 ° 53 ' 2.7400 " 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 ❑ NO g/
c. WATER LEVEL Below Top of Casing: 4.0
(Use "+" if Above Top of Casing)
FT.
8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. PORTLAND BENTONITE 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 Size Material
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
:
•
•
•
•
•
•
•
•
•
•
•
•
Formation Description
ASPHALT/GRAVEL
GRAY SILTY SAND
12. REMARKS:
: BENTONITE SEAL FROM 3,0 TO 4.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO D S BEEN PROVIDED T,Q THE WL OWNER.
vItt,.
SIGNATURE QF CERTIFIED WEL
VINCE FEDERLE
02/18/13
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit within 30 days of completion to: Divisi©n:'•
of Water Quality -; Information Proces 'Inc
17 Mail Service Center, Raleigh, NC 27699-161, Phone [phone]
DATE
Form GW-1 b
Rev. 2/09