387137_Well Construction - GW1_20100928

NONRESIDENTIAL WELL CONSTRUCTION RECORD 9 ( f7 41 }
` North Calohna Depa tment of E-nvnonment and Natut al Resources- Division of Water,Quality tJ( ( - es t+
WELL CONTRACTOR CERTIFICATION # 2579
1 WELL CONTRACTOR
DANNY SUMMERS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD
STATESVILLE NC
28625
City or Town State Zip Code
( 704 )_ 872-7686
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) MW-14
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ® Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection o
Irrigation❑ Other 0 (list use)
DATE DRILLED 09/17/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY WALLACE COUNTY DUPLIN
208 NORTH NORWOOD STREET 28466
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑ Flat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4 FACILITY- is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY SCOTCHMAN - 28
STREET ADDRESS 208 NORTH NORWOOD STREET
WALLACE
NC 28466
City or Town State Zip Code
CONTACT PERSON WORSLEY OPERATING CORPORATION
MAILING ADDRESS PO BOX 3227
WILMINGTON NC
28406
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 13 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 4 0 FT
(Use "+" if Above Top of Casing)
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 vitth 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)
From To From To
From To From To
From To From To
6 CASING Thickness/
Depth Diameter Wg iQ ht Material
From 0 0 To 3 0 Ft 2 INCH SCii40 PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 0 To 1 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 3 0 To 13 0 Ft 2 0 in 010 in PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 2 0 To 13 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To
00 50
50 100
10 0 13 0
Formation Description
BROWN/GRAY CLAYEY SAND
GRAY SILTY CLAY
GRAY SAND
11 REMARKS
BENTONITE SEAL FROM 1 0 TO 2 0 FT
I D0 HEREBY CERTIFY THAT THIS WELL WAS : ONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CON TRUCTION STAND DS AND THAT A COPY OF THIS
RECO AS BEEN PR*. ' 0ED TO THE WE •WNER
SIG
.�09/20/10
RTIFIEeir1 �LCONTRACTOR DATE
DANNY SUMMERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days �Attn Information Mgt ,
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7/05
Information Processing UnitR
DWQ2BgQ 2010 Revev 7/05 1b
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No (919) 733 7A.5, xt 568
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