412543_Well Construction - GW1_20130408

C
e
ESI
EIS HAL WELL CONST
UCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
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#
OTHER ASSOCIATED PERMIT#Of applicable)
SITE WELL ID #(if applicable) MW-1 l
3. WELL USE (Check One Box) Monitoring [i Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 03/06/13
4. WELL LOCATION:
164 INDUSTRIAL DRIVE 28472
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WH ITEVILLE
COUNTY COLUMBUS
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley Flat 0 Ridge ❑ Other
LATITUDE 34 ° 19 • 57.6500 "DMS OR
LONGITUDE 78 ° 42 • 59.3800 „ DMS OR
Latitude/longitude source: VGPS ❑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.)
NC REMEDIAL INVESTIGATION N/A
DD
DD
Facility Name Facility ID# (if applicable)
164 INDUSTRIAL DRIVE
Street Address
WHITEVILLE •NC 28472
City or Town • State Zip Code
MARKOVITZ ENTERPRISES, INC
Contact Name
100 BADGER DRIVE
Mailing Address
ZELIENOPLE
City or Town
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 15.0 FEET
PA 16063
State Zip Code
•
•
•
•
R1 F Qt~ �`w� •�Y�
d. TOP OF CASING IS 2.5 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 NIA
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 r, aterial
Top 0.0 Bottom 5.0 FL 2 INCH SCH 40 PVC
Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. PORTLAND BENTONITE SLURRY
: Top Bottom Ft.
: Top Bottom Ft.
: 9. SCREEN: Depth Diameter Slot Size Material
•
Top 5.0 Bottom 15.0 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 4.0 Bottom 15.0 Ft. 20-40
Top Bottom Ft.
•
•
•
/
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 0.5
0.5 / 8.0
8.0 / 15.0
FINE SILICA SAND
Formation Description
DARK GRAY SILTY SAND
YELLOW/ORANGE SANDY CLAY
LIGHT GRAY SILTY CLAY
/ aB
•
0 e 2013
•
12. REMARKS:
: BENTONITE SEAL FROM 3,0 TO 4,0 FEET
I DO HEREBY
• 15A NCAC 2
• RECORD
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO at
c. WATER LEVEL Below Top of Casing: 3.41 FT.
(Use "+" if Above Top of Casing)
UCTED IN ACCORDANCE WITH
AND THAT A COPY OF THIS
03/11/13
SI TURE OF CERTIFIED WELL CONTRACTOR DATE
: JAMES HESS
•
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09