389094_Well Construction - GW1_20101112

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natut al Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3098
1 WELL CONTRACTOR
JOHNNY BURR
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD
STATESVILLE NC
28625
City or Town State Zip Code
( 704 )_ 872-7686
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) MW-10
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring J Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/11/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY SILOAM
3975 NC HIGHWAY 268 27047
COUNTY SURRY
(Street Name, Numbers, Community, Subdivision
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑ Valley ❑ Flat ❑ Ridge 0 Other
(check appropnate box)
LATITUDE _
LONGITUDE
Latitude/longitude source
Lot No Parcel, Zip Code)
May be in degrees,
minutes, seconds or
in a decimal format
❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4 FACILITY- is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY HOWARD BOLES PROPERTY
STREET ADDRESS 3975 NC HIGHWAY 268
SILOAM
NC 27047
City or Town
State Zip Code
CONTACT PERSON HOWARD BOLES
MAILING ADDRESS
PO BOX 38
PINNACLE NC
27043
City or Town State Zip Code
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 45 0 FEET
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 35 0 FT
(Use "+" if Above Top of Casing)
3890.1
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)
From To From To
From To From To
From To From To
6 CASING Thickness/
Depth Diameter W i ht Material
From 0 0 To 30 0 Ft 2 INCH SCi�4b PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 0 To 25 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 30 0 To 45 0 Ft 2 0 in 010 in PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 28 0 To 45 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
00 100 RED CLAY
10 0 45 0 TAN SANDY CLAY
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laformatron
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11 REMARKS
BENTONITE SEAL FROM 25 0 TO 28 0 FT
100 HEREBY CERTIFY THAT THIS WELL ' S CONSTRUCTED IN ACCORDANCE WITH
15A N C 2C WELL CON TRUCTION S' DARDS AND THATA COPY OF THIS
REC•'I HA'. BEENPR• IDEDTOTH: ^' LLO�WNERR
�� 04 10/19/10
ATUR:(.' CERTIFIED WELL CONTRACTOR DATE
JOHNNY BURR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn Information Mgt ,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-1b
Rev 7/05

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