411539_Well Construction - GW1_20130211

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE
City or Town
( 704 ) 872-7686
17,
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
Area code Phone number
• Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# : Top 0.0 Bottom 2.0 Ft. 2 INCH SCH 40 PVC
NC 28625
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
Top Bottom Ft.
SITE WELL ID #(if applicable) MW-5 : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ri Municipal/Public ❑ : 8. GROUT: Depth Material Method
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection ❑ : Top 0.0 Bottom 1.0 Ft. PORTLANDBENTONITE SLURRY
Irrigation❑ Other 0 (list use) : Top Bottom Ft.
DATE DRILLED 01 /22/13 : Top - Bottom Ft.
4. WELL LOCATION:
100 WEST SALISBURY STREET 28480
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WRIGHTSVILLE BEACH COUNTY NEW HANOVER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope [Valley f(Flat DRidge DOther
LATITUDE 34 ° 13 • 5.1800 "DMS OR DD
LONGITUDE 77 ° 47 • 45.9800 " DMS OR DD
Latitude/longitude source: VIGPS ❑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.)
WRIGHTSVILLE BEACH FOOD MART N/A
Facility Name Facility ID# (if applicable)
100 WEST SALISBURY STREET
Street Address
WRIGHTSVILLE BEACH
City or Town
SPRINGER EUBANKS
NC 28480
State Zip Code
Contact Name
123 SHIPYARD BLVD
Mailing Address
WILMINGTON NC 28412
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO GI
c. WATER LEVEL Below Top of Casing: 5.0
(Use "+" if Above Top of Casing)
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. in.
: Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
: Top 1.5 Bottom 12.0 Ft. 20-40 FINE SILICA SAND
Top Bottom Ft.
Top Bottom Ft.
= 11. DRILLING LOG
: Top Bottom Formation Description
0.0 I 1.0
1.0 / 12.0
/
TOPSOIL
DARK GRAY SANDY SILT
C ENE D
t= l=k 1) 4 2013
4rtformation Processing Unit
DWQ/BOG
12. REMARKS:
: BENTONITE SEAL FROM 1.0 TO 1.5 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH , ,,
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS,
RECORD S BEEN PROVIDED TO THE WELL OWNER.
SIGNA
RTIFIED WEL
: VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING TH
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--Rev. 2/09