411538_Well Construction - GW1_20130211

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1. WELL CONTRACTOR:
VINCE FEDERLE
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
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#(if applicable)
SITE WELL ID #(if applicable) MW-6
3. WELL USE (Check One Box) Monitoring v� Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 01/22/13
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)
❑Slope ❑Valley fifFlat ❑ Ridge DOther
LATITUDE 34 ° 13 ' 5.0800 "DMS OR DD
LONGITUDE 77 ° 47 ' 45.9800 " DMS OR DD
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.)
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
State
28480
Zip Code
Contact Name
123 SHIPYARD BLVD
Mailing Address
WILMINGTON
City or Town
NC 28412
State Zip Code
( )
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 12.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qI
c. WATER LEVEL Below Top of Casing: 5.0
(Use "+" if Above Top of Casing)
FT.
•
•
•
•
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.
r.
338
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type NIA 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 SCH 40 PVC
Top Bottom . Ft.
: Top Bottom Ft.
: 8. GROUT: Depth Material
Top 0.0 Bottom 1.0 Ft. PORTLAND BENTONITE
Top Bottom Ft.
: Top Bottom Ft.
Method
SLURRY
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 / 1.0
: 1.0 / 12.0
ASPHALT/GRAVEL
DARK GRAY SANDY SILT
E
FER Es 4 2013
riforn-ls,tion Processing Unit
OWQ/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 HAS BEEN PROVIDED TO THE WELL OWNER.
= SIG
: VINCE FEDERLE
W
01/25/13
PRINTED NAME OF PERSON CONSTI 11CTING THE WELL
� FEB 12013
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Form GW-1 i;:
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