398182_Well Construction - GW1_20110923

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4121
1. WELL CONTRACTOR:
NICHOLAS HAYES
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
State
28625
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) PMW-3
3. WELL USE (Check One Box) Monitoring p" Municipal/Public 0
Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 08/25/11
4. WELL LOCATION:
3000 US HIGHWAY 74 EAST 28110
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: MONROE COUNTY UNION
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope DValley ❑ Flat ❑ Ridge ❑ Other
LATITUDE "DMS OR
LONGITUDE " DMS OR
DD
DD
Latitude/longitude source: D3PS EiTopographic 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.)
NORTON DOOR CONTROL
N/A
Facility Name
3000 US HIGHWAY 74 EAST
Facility ID# (if applicable)
Street Address
MONROE
City or Town
YALE SECURITY, INC
NC 28110
State Zip Code
Contact Name
3000 US HIGHWAY 74 EAST
Mailing Address
MONROE
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25.0 FEET
b. DOES WELL REPLACE EXISTING WELL?
NC 28110
State Zip Code
YES ❑ NO q/
c. WATER LEVEL Below Top of Casing: 20.0
(Use "+" if Above Top of Casing)
ubmltwithln 30 days of completion to.,
16177Mail Serrvice,tCenter, Raleigh, NC 2769941
FT.
IVISIon o
;Phone:
3981.82
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
7. CASING: Depth
Top 0.0 Bottom 15.0
Top 0.0 Bottom 12.0
Top Bottom
Thickness/
Diameter Weight Material
Ft. 2 INCH SCH ao PVC
Ft. 6 INCH SCH ao PVC
Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 10.0 Ft.
Top 0.0 Bottom 12.0 Ft.
Top Bottom . Ft.
PORTLAND BENTONITE
PORTLAND BENTONITE
Method
SLURRY
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 15.0 Bottom 25.0 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 13.0 Bottom 25.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 11.0
11.0 / 25.0
FINE SILICA SAND
Formation Description
TAN SANDY SILT
WHITE/GRAY SILT/STONE
e`4k, lie I' i
u r
tP 2 %l.iii
YU.�iuf Wdiiul
u
12. REMARKS:
BENTONITE SEAL FROM 10.0 TO 13.0 FEET
I DO HEREBY C
15A NCAC 2C
RECORD HA
WELL WAS CONSTRUCTED IN ACCORDANCE WITH
RDS, AND THAT A COPY OF THIS
OWNER.
SIGNATURE OF CERTIFIED
NICHOLAS HAYES
08/31/11
LL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ater Quasi
119)807-63clalWatair
Form GW-1 b
Rev. 2/09