397582_Well Construction - GW1_20110926

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
JAMES HESS
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 #(i( applicable) MW-11R
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 08/16/11
4. WELL LOCATION:
1339 SOUTH MADISON STREET 28472
(Street Name, Numbers, Community. Subdivision, Lot No., Parcel, Zip Code)
CITY: WHITEVILLE COUNTY COLUMBUS
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope oValley ❑Flat ❑Ridge ❑Other
LATITUDE " DMS OR DD
LONGITUDE ° " DMS OR DD
Latitude/longitude source: COPS ❑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.)
FMR SCOTCHMAN - 174
N/A
Facility Name Facility ID# (if applicable)
1339 SOUTH MADISON STREET
Street Address
WHITEVILLE NC 28472
City or Town State Zip Code
WORSLEY FAMILY HOLDINGS
Contact Name
123 SHIPYARD BLVD
Mailing Address
WILMINGTON
City or Town
NC 28412
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO
c. WATER LEVEL Below Top of Casing: 4.0
(Use "+" if Above Top of Casing)
FT.
3550
d. TOP OF CASING IS 0.0 FT. Above Land Surface*
*Top of casing terminated aVor 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 2.0 Ft. 2 INCH SCH40 PVC
Top Bottom Ft.
Top Bottom FL
8. GROUT: Depth Material Method
Top 0.0 Bottom 0.5 Ft. PORr1ANO BENTONITE SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 2.0 Bottom 12.0 Ft. 2.0 in. .010 in. PVC
Top Bottom Ft. in.
Top Bottom Ft. in.
in:
in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 1.0 Bottom 12.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
12. REMARKS:
FINE SILICA SAND
Formation Description
BROWN SILTY SAND
GRAY CLAY
BENTONITE SFAI FROM 0.5 TO 1 0 FEET
I DO HEREBY *yf'TIFY THAT THIS WELL WAS CONSTRUCT N ACCORDANCE WITH
15ANCAC %F' ELL CONS N999''THH7@@@ ARDS. AND ,Y F ACOPY OF THIS
RECORDDE QTHE �O ER
08/22/11
JAMES HESS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Siit mmit withln'30 days of completion to Dtvisiop of Water Quality information Processing;
` 1617yMail Service Center, Raleigh NC 27699 161 !Phone {8.I9J 807 6304 t - x `
Form GW-1 b
Rev. 2/09
1r4