412552_Well Construction - GW1_20130408

NRESPFAT
T1AIL WELL CONSTrvIUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
JOHNNY BURR
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# WM0800984
OTHER ASSOCIATED PERMIT#(if applicable) WV0800073
SITE WELL ID #(if applicable) MW-27R
3. WELL USE (Check One Box) Monitoring Mt Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
IrrigationD Other 0 (list use)
DATE DRILLED 03/06/13
4. WELL LOCATION:
407 SOUTH MARINE BLVD 28540
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: JACKSONVILLE COUNTY ONSLOW
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Slope ❑Valley Ir'Flat ❑Ridge ❑Other
LATITUDE 34 ° 45 ' 5.1400 " DMS OR
LONGITUDE 77 ° 26 ' 51.1000 " DMS OR
Latitude/longitude source: {PS Qropographic map
(location of welt must be shown on a USGS topo map andattached to
this form ifnot using GPS)
5. FACILITY (Name of the business where the well is located.)
ONSLOW OIL
N/A
DD
DD
Facility Name Facility ID# (if applicable)
407 SOUTH MARINE BLVD
Street Address
JACKSONVILLE
City or Town
WORSLEY FAMILY HOLDINGS
NC 28540
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: 12.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [/
c. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use "+" if Above Top of Casing)
3093
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
7. CASING: Depth Diameter
Top 0.0 Bottom 2.0 Ft. 2 INCH
Top Bottom Ft.
Top Bottom Ft.
Top Bottom
Top Bottom
Top Bottom
Thickness/
Weight
SCH 40
8. GROUT: Depth Material
Top 0.0 Bottom 1.0 Ft. PORTLAND BENTONITE
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top 2.0 Bottom 12.0 Ft. 2.0 in.
Top Bottom Ft. in.
Top Bottom Ft.
Material
PVC
Method
SLURRY
Slot Sae
.010 in
in
in. in.
Material
PVC
10. SAND/GRAVEL PACK:
Depth Size Material
Top 1.5 Bottom 12.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 1.0
1.0 / 6.0
6.0 / 12.0
FINE SILICA SAND
Formation Description
BROWN/BLACK TOPSOIL
GRAY SANDY CLAY
GRAY SAND
12. REMARKS:
BFNTONITE SFAI FROM 1 0 TO 1 5 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC2C, WELL CONSTRUCTION NDARDS, AND THATA COPY OF THIS
RE : D S BEEN PRVIDED TO TSF/WELL OWNER.
03/11/13
TU' 4' CERTIFIEDtPELL CONTRACTOR DATE
JOHNNY BURR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ubmit 7lrllfhi 130 days,of completion to Division of Water Qualit
>"17 Mad Service Center<Raletgh;.limt 27699-161' 'Phone [phone]
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Form GW-lb
Rev. 2/09