398181_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 28625
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(f applicable) PMW-2
3. WELL USE (Check One Box) Monitoring CI Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 08/25/11 - 08/29/11
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 [Valley ❑Flat ❑Ridge ID Other
LATITUDE
LONGITUDE
" DMS OR
" DMS OR
DD
DD
Latitude/longitude source: BPS DTopographic 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 Facility ID# (if applicable)
3000 US HIGHWAY 74 EAST
Street Address
MONROE
City or Town
YALE SECURITY, INC
Contact Name
3000 US HIGHWAY 74 EAST
NC 28110
State Zip Code
Mailing Address
MONROE
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 31.0 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)
ubmitOwl
46171MaiI Service;
rrpletion to
NC'2769
FT.
AfigR
IVislon of Wateri.Qua.
one : 219Y13. 0:746
d. TOP OF CASING IS _ 0.0 FT. Above LandSurface*
*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
Top 0.0 Bottom 21.0 Ft. 2 INCH SCH 40
Top 0.0 Bottom 15.0 Ft. 6 INCH SCH 40 PVC
Material
PVC
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 16.0
Top 0.0 Bottom 15.0
Top Bottom Ft.
Material
Ft. PORTLAND BENTONITE
Ft. PORTLAND BENTONITE
Method
SLURRY
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 21.0 Bottom 31.0 Ft. 2.0 in. .010 in. PVC
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Top 19.0 Bottom 31.0
Top
Top
Bottom
Bottom
11. DRILLING LOG
Top Bottom
in. in.
in. in.
Size Material
Ft. 20-40
Ft.
Ft.
FINE SILICA SAND
Formation Description
0.0 / 14.0 TAN SANDY SILT
14.0 / 31.0 WHITE/GRAY SILT/STONE
1D .. p " �"O R
SEP 2 /Itll
1FQrrn tjcfl ",uuftssFng Unit
12. REMARKS:
BENTONITE SEAL FROM 16.0 TO 19.0 FEET
I DO HEREBY C
15A NCAC 2C,
RECORD HAS 8E
SIGNATURE OFtERTIFIED
NICHOLAS HAYES
LL WCONSTRUCTED IN ACCORDANCE WITH
DS, AND THAT A COPY OF THIS
WNER.
08/31/11
L CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
rocessmg
Form GW-1 b
Rev. 2/09

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