411540_Well Construction - GW1_20130204

NONRESIDENTIAL 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
City or Town
( 704 ) 872-7686
NC 28625
State Zip Code
111. 1 r; 0
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
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom , Top
N/A
N/A
Bottom
Bottom
: Top Bottom Top Bottom
Area code Phone number
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight
WELL CONSTRUCTION PERMIT# : Top 0.0 Bottom 2.0 FL 2 INCH SCH 40
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-4
3. WELL USE (Check One Box) Monitoring i Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 01/22/13 - 01/23/13
4. WELL LOCATION:
100 WEST SALISBURY STREET 28480
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WRIGHTSVILLE BEACH COUNTY NEW HANOVER Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Valley litrFlat ❑Ridge ❑Other
Top Bottom Ft.
Top Bottom Ft.
: 8. GROUT: Depth Material
Top 0.0 Bottom 1.0 Ft. PORTLAND BENTONITE
Top Bottom Ft.
: Top Bottom Ft.
Material
PVC
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 2.0 Bottom 12.0 Ft. 2.0 in. .010 in. PVC
Bottom Ft. in. in.
LATITUDE 34 ° 13 5.2100 "DMS OR DD
LONGITUDE 77 ° 47 ' 46.4200 " DMS OR DD
Latitude/longitude source: , (GPS ['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.)
WRIGHTSVILLE BEACH FOOD MART N/A
Facility Name
100 WEST SALISBURY STREET
Street Address
WRIGHTSVILLE BEACH
City or Town
SPRINGER EUBANKS
Contact Name
123 SHIPYARD BLVD
Facility ID# (if applicable)
NC 28480
State Zip Code
Mailing Address
WILMINGTON NC 28412
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO QI
c. WATER LEVEL Below Top of Casing: 5.0 FT.
(Use "+" if Above Top of Casing)
•,..,��:.,:�.:•:,.r tr-._:/ it `y,,.
ii�mit within `30 days of�com letio' i "1
�17�Mail Service Centers Raleig-h; f - ;r
: Top
Top
'= '�ivision of Water Qualif
10. SAND/GRAVEL PACK:
Depth Size Material
Top 1.5 Bottom 12.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
FINE SILICA SAND
11. DRILLING LOG
Top Bottom Formation Description
: 0.0 / 1.0 TOPSOIL
• 1.0 / 12.0 DARK GRAY SANDY SILT
. /
: /
• /
•
•
•
•
•
•
:information Processing Unit
12. REMARKS: DWQ/BOG
BENTONITE SEAL FROM 1.0 TO 1.5 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDCE WITH
• 15A NCAC 2 , WELL CONSTRUCTION STANDARDS, AND THAT A COPY\THI
RECO S BEN PRO IDE THE W OWNER.
•
• '��N x f �9a r'`
•
'r 01 /25/1
• SIGNATURE OF CERTIFIED WELL GpN1 RAC 'OR DATE't'
• +�?•h fk��ry7 t t,:
•
VINCE FEDERLE ,,gin
. PRINTED NAME7,11046 OF PERSON COf����RUTHE WELL �••,,,,.��
Form GW-1 b
Rev. 2/09