411388_Well Construction - GW1_20130211

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N - ESItENTIAL WELL CONST UCTION ECO D
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR ICE
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
TIFICAT!ON # 355.E
Street Address
STATESVILLE
City or Town
( 704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC
State
28625
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-3
3. WELL USE (Check One Box) Monitoring ri Municipal/Public 0
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection 0
Irrigationo Other 0 (list use)
DATE DRILLED 01/23/13
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 ufFlat ❑ Ridge ❑ Other
LATITUDE 34 ° 13 ' 4.8100 "DMS OR
LONGITUDE 77 ° 47 46.6000 " DMS OR
Latitude/longitude source: V3PS ❑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
Contact Name
123 SHIPYARD BLVD
Mailing Address
WILIVIINGTON
City or Town
DD
DD
NC 28480
State Zip Code
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 ❑
c. WATER LEVEL Below Top of Casing: 5.0
(Use "+" if Above Top of Casing)
nnaII � er �ce� Lev er
completion to
aIeigh,��P
t tt
NO ri
FT.
IT it
el 0
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
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 Method
Top 0.0 Bottom 1.0 Ft. PORTLAND 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. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
: Top 1.5 Bottom 12.0 Ft. 20-40
: Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
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FINE SILICA SAND
Formation Description
0.0 / 1.0 TOPSOIL
1.0 / 12.0 DARK GRAY SANDY SILT
/
V'FB - 1 zo,?,
e.S'; 9
• 12. REMARKS: --.
P .
BENTONITE SEAL FROM 1.0 TO 1.5 FEET n4:051l a`t't o
n• tp�L,,:
OG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECORHAS BEEN PROVIDED TO THE WELL OWNER.
SIG
eliCER
: VINCE FEDERLE
PRINTED NAME OF PERSON CONS*
ormati:
i01 /25/13
R�C'TOR DA, E
t`'-; s7+v'7 Y "ley , JJJ uaw:f'' F i P
CTING THE WELL
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