387138_Well Construction - GW1_20100928

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envuonment and Natural Resources- Division of Water Quality
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-15
STATE WELL PERMIT#Of applicable)
DWQ or OTHER PERMIT Of applicable)
WELL USE (Check Applicable Box) Monitoring E Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (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 'Walley ❑Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE
LONGITUDE
Latitude/longitude source
May be in degrees,
minutes, seconds or
in a decimal format
❑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
130FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO E
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 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)
From To From To
From To From To
From To From To
6 CASING Thickness/
Depth Diameter W i ht Material
From 0 0 To 3 0 Ft 2 INCH 5L1-f40 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
100
50
100
130
Formation Description
BROWN/GRAY CLAYEY SAND
GRAY SILTY CLAY
GRAY SAND
11 REMARKS
BENTONITE SEAL FROM 1 0 TO 2 0 FT
I DO HEREBY CERTIFY THAT THIS WELL
15 AC 2C WELL STRUCTION ST
R�OIFD HAS BEEN VIDGA TO THE
Tow►.
ATURE OF CERTIFIED WELL CONTRACTOR DATE
CONSTRUCTED IN ACCORDANCE WITH
ARDS AND THAT A COPY OF THIS
LL OWNER
'"". 09/20/10
DANNY SUMMERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days Attn Iij ! . I eCE/ rm GW-1b
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No [phone] ext 568 VE 7/05
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