390914_Well Construction - GW1_20110120

.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
NC 28625
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) MW-26D3
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 11/17-12/06/10, 12/29/10-1/6/11
4. WELL LOCATION:
3000 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 ❑Other
LATITUDE °
LONGITUDE
" 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.)
NORTON DOOR CONTROL N/A
Facility Name Facility ID# (if applicable)
3000 HIGHWAY 74 EAST
Street Address
MONROE
City or Town
NORTON DOOR CONTROL
NC 28110
State Zip Code
Contact Name
3000 HIGHWAY 74 EAST
Mailing Address
MONROE
City or Town
NC 28110
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 640.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ltlr
c. WATER LEVEL Below Top of Casing: 603.00 FT.
(Use •'+" if Above Top of Casing)
1 .
Sul (1,1
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
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth Diameter
Top 0.0 Bottom 400.0 Ft. 10 INCH
Top 0.0 Bottom 550.0 Ft. 61/4INCH
Top 0.0 Bottom 630.0 Ft. 4 INCH
8. GROUT: Depth
Top 0.0 Bottom 400.0
Top 0.0 Bottom 550.0
Top 0.0 Bottom 630.0
9. SCREEN: Depth
Top Bottom
Top Bottom
Top Bottom
10. SAND/GRAVEL PACK:
Depth
Top Bottom
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0.0
30.0
35.0
30.0
35.0
640.0
Ft.
Ft. PORTLAND BENTONITE
Ft. PORTLAND BENTONITE
Material
Amount N/A
Bottom
Bottom
Bottom
Thickness/
Weight
.242
.188
.188
PORTLAND BENTONITE
Material
STEEL
GALVANIZED
STEEL
Method
SLURRY
SLURRY
SLURRY
Diameter Slot Size Material
Ft. in. • in.
Ft. in. in.
Ft. in. in.
Ft.
Ft.
Ft.
Size
Material
Formation Description
BROWN SILT/ROCK LAYERS
WEATHERED ROCK
GRAY ROCK
JAN 2 0 201i
WATER QUAI try
hduNn:qlon Process rig t°,r�
12. REMARKS:
OPEN HOLE FROM 630.0 TO 640.0 FT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION ST • 1 •-" DS, AND THAT A COPY OF THIS
RECORD H • BEEN PROVIDED "1 TH:r 1. L OWNER.
SIGNAT
F CERTIFIED W
01/17/11
LL CONTRACTOR DATE
JASOO MANTAK
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
utimlt within 30 days of completion tod Division of: Water Quali
617 Mail,Servlce Center Raleigh,• NC 27699 161 Phone,. (919):807 63,
fomati'onlProcessing
Form GW-lb
Rev. 2/09

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