398942_Well Construction - GW1_20111021 (2)

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2345
1. WELL CONTRACTOR:
MARK GETTYS
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#
N/A
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) SVE-2
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 09/28/11
4. WELL LOCATION:
13024 EAST INDEPENDENCE BLVD 28105
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STALLINGS COUNTY UNION
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑Valley ❑Flat DRidge ❑Other
LATITUDE "DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: D3PS [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.)
RMR - 2364 N/A
Facility Name Facility ID# (if applicable)
13024 EAST INDEPENDENCE BLVD
Street Address
STALLINGS NC 28105
City or Town State Zip Code
CONOCO PHILLIPS
Contact Name
420 SOUTH KEELER AVENUE
Mailing Address
BARTLESVILLE OK 74006
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 p/
c. WATER LEVEL Below Top of Casing: 13.0 FT.
(Use "+" if Above Top of Casing)
Ion to Division o
ail Service Center IRaleigh, NC 27699 161, Phone
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 5.0 Ft. 4 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 1.0 Ft. PORTLANDBENTONITE SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 15.0 Ft. 4.0 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 3.0 Bottom 15.0 Ft. 20-40 FINE SILICA SAND
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0.0 / 5.0 ORANGE SILTY SAND
5.0 / 15.0 BROWN/ORANGE SILTY CLAY
/ l'I l 2 7 ZU 11
/ ;1ItOrfllatinn f'dd ss�t
/ ne4,�/a©(., 9 Unit
12. REMARKS:
BENTONITE SEAL FROM 1.0 TO 3 0 FFET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
S BEENigROVITO THE WILLLOWNER.
SIGNATURE OF CERTIFIED WELL CONTRACTO
MARK GETTYS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09