393685_Well Construction - GW1_20110509

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NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2580
1. WELL CONTRACTOR:
JASON MANTAK
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# N/A
NC 28625
State Zip Code
OTHER ASSOCIATED PERMIT#Q( applicable)
SITE WELL ID #(if applicable) MW-3
3. WELL USE (Check One Box) Monitoring El Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 04/04/11
4. WELL LOCATION:
3012 MASON STREET 28110
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: MONROE COUNTY UNION
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
0Slope [Valley ❑Flat ❑Ridge ❑Other
LATITUDE
LONGITUDt
" DMS OR
" DMS OR
DD
DD
Latitude/longitude source: E3PS [(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.) .
COOPER HAND TOOLS N/A
Facility Name Facility ID# (if applicable)
3012 MASON STREET
Street Address
MONROE
City or Town
COOPER HAND TOOLS
NC 28110
State Zip Code
Contact Name
3012 MASON STREET
Mailing Address
MONROE
City or Town
NC 28110
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 30.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO D(
c. WATER LEVEL Below Top of Casing: 22.0 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING 1S 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
Top Bottom Top
N/A
N/A
Bottom
Bottom
Bottom
Thickness/
7. CASING: " Depth Diameter Weight Material
Top 0.0 Bottom 20.0 Ft. 2 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 14.0
Top Bottom
Top Bottom
9. SCREEN: Depth
Top 20.0 Bottom 30.0
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top 18.0 Bottom 30.0
Top
Top
Material
Ft. PORTLAND BENTONITE
Ft.
Ft.
Method
SLURRY
Diameter Slot Size Material
Ft. 2.0 in. .010 in. PVC
Ft. in. in.
Ft. in. in.
Size Material
Ft. 20-40
Bottom Ft.
Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 3.0
3.0 / 23.0
23.0 / 30.0
FINE SILICA SAND
Formation Description
TAN CLAY
TAN MUDSTONE
TAN/GRAY MUDSTONE
MAY 9 2 i i i
;rttorrnaltofl f'IULcSoi�
uwn`C;CCG
12. REMARKS:
BENTONITE SEAL FROM 14.0 TO 18.0 FEET
ID0 HEREBY
15A NCAC 2
RECORD HA
RTIFY THAT THIS
ELL CONST
ROVID
ELL
SONSTRUCTED IN ACCORDANCE WITH
ARDS, AND THAT A COPY OF THIS
L OWNER.
04/11/11
SIGNAT OF CERTIFIED WELL CONTRACTOR DATE
JASON MANTAK
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submitwithin 30 days of completion to: Division. of Water Quality Information Processing,
1617 Mail ServiceCenter, Raleigh, NC 27699 161, Phone.: [phone]
Form GW-lb
Rev. 2/09
c.)