411537_Well Construction - GW1_20130211

NON RESIDENTIAL 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
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28625
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) DW-1
3. WELL USE (Check One Box) Monitoring pl 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
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope DValley itFlat ❑Ridge ❑Other
LATITUDE 34 ° 13 .5.0100 "DMS OR DD
LONGITUDE 77 ° 47 ' 46.3400 " DMS OR DD
Latitude/longitude source: EGPS ❑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 Facility ID# (if applicable)
100 WEST SALISBURY STREET
Street Address
WRIGHTSVILLE BEACH
City or Town
SPRINGER EUBANKS
NC 28480
State Zip Code
Contact Name
123 SHIPYARD BLVD
Mailing Address
WILMINGTON NC 28412
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 28.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO GI
c. WATER LEVEL Below Top of Casing: 5.0 FT.
(Use "+" if Above Top of Casing)
Submit'within 3a rd }/s of completion to: Division a
I
Mail Service Center Raleigh; NG 27699-16'�•Pho
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
Thickness/
:7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 23.0 Ft. 2 INCH SCH 40 PVC
Top 0.0 Bottom 18.0 Ft. 6 INCH SCH 40 PVC
: Top Bottom Ft.
: 8. GROUT: Depth Material Method
Top 0.0 Bottom 18.0 Ft. PORTLAND BENTONITE SLURRY
Top Bottom Ft.
: Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 23.0 Bottom 28.0 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 21.0 Bottom 28.0 Ft. 20-40 FINE SILICA SAND
: Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom Formation Description
0.0
1.0
19.0
20.0
21.0
22.0
1.0
19.0
20.0
21.0
22.0
28.0
TOPSOIL
DARK SANDY SILT
LIMESTONE
DARK GRAY SAND
LIMESTONE
DARK GRAY SAND
1VE
ormatun IUt.;elssIIty Utlft
▪ 12. REMARKS: D\NQ/BOG
: BENTONITE SEAL FROM 18.0 TO 21.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAGS BEEN PROVIDED TQ.THE WE OWNER.
SIGNATURE OF CERTIFIED WEL
01/25/13
DATE
: VINCE FEDERLE
: PRINTED NAME OF PERSON CONSTRUCTILN;GTI E WEL „'
Y1 I
FEB Far r �r '■r`_
Rev. 2/09