WQ0000601_GW Wells_20120228

N
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2581
1. WELL CONTRACTOR:
BRIAN THOMAS
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
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
: d. TOP OF CASING IS 2.5 FT. Above Land Surface'
'Top of casing terminated attor 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
c
Top 0.0 Bottom 50.0 Ft. 2 INCH SCH 40 PVC
OTHER ASSOCIATED PERMIT#(if applicable) : Top Bottom Ft.
SITE WELL ID #(if applicable) MW-11 : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 02/20/12
4. WELL LOCATION:
173 CSX DRIVE 28345
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: HAMLET COUNTY RICHMOND
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge []Other
LATITUDE _°_' "DMS OR DD
LONGITUDE _°_' " DMS OR DD
Latitude/longitude source: D3PS aopographic 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.)
r.C-SX HAML-E-T-YARD
N/A
Facility-Name--""�"'""'�-
Facility ID# (if applicable)
173"GSX_DRIVEQ
Street Address
LE-TE)
NC 28345
City or Town
State Zip Code
CSX TRANSPORTATION INC
Contact Name
351 THORNTON ROAD SUITE 125
Mailing Address
LITHIA SPRINGS
GA 30122
City or Town
State Zip Code
U
Area code Phone number
6. WELL'DETAILS:
a. TOTAL DEPTH: 65.'0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO G/
c. WATER LEVEL Below Top of Casing: 52.0
(Use "+" if Above Top of Casing)
8. GROUT:
Depth
Material Method
: Top 0.0
Bottom 45.0
Ft.
PORTLANDBENTONITE SLURRY
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter
Slot Size Material
: Top 50.0
Bottom 65.0
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 48.0
Bottom 65.0
Ft. 2040 FINE SILICA SAND
Top
Bottom
Ft.
Top
Bottom
Ft.
'
11. DRILLING LOG
Top
Bottom
Formation Description
0.0 /
6.0
RED SILTY SANDY CLAY
6.0 /
18.0
TAN SILTY SANDY CLAY
18.0 /
34.0
TAN SANDY CLAY
34.0 /
65.0
TAN/WHITE SAND ..., tom, e°,, r°��.•
I i
12. REMARKS:
BENTONITE SEAL FROM 4
0
TO 48.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
Ir VC5kD HAS BEEN PROviDEDT WELL OWNER.
` �_ 28/ 12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
BRIAN THOMAS
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

STAtt
NONRESIDENTIAL ONRESIDENTIAL WELL CONSTRUCTION RECORD
J C North Carolina Department of Environment and Natural Resources- Division of Water Quality
',•�,"•� WELL CONTRACTOR CERTIFICATION # 2581
1. WELL CONTRACTOR:
BRIAN THOMAS
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
7( 04 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) mm2
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
IndustriaUCommercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 02/21/12
4. WELL LOCATION:
173 CSX DRIVE 28345
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY; HAMLET COUNTY -RICHMOND
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat pRidge ❑Other
LATITUDE • "DMS OR DD
.LONGITUDE " DMS OR DD
L'atitudedongitude source: BPS Ofopographic 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.)
CSX HAMLET YARD WWTP
N/A
Facility Name
Facility ID# (if applicable)
173 CSX DRIVE
Street Address
HAMLET
NC
28345
City or Town
State
Zip Code
CSX TRANSPORTATION, INC.
Contact Name
351 THORNTON ROAD SUITE 125
Mailing Address
LITHIA SPRINGS
GA
30122
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 50.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p/
c. WATER LEVEL Below Top of Casing: 47.0 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 2.5 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 35.0
Ft. 2 INCH
SCH 40 PVC
Top Bottom
Ft. '
Top Bottom •
Ft.
: 8. GROUT:
Depth
Material Method
Top 0.0
Bottom . 30.0
Ft.
PORTLANDBENTONITE SLURRY
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter Slot Size Material
Top '35.0
Bottom 50.0
Ft.
2.0 in. .010 in. PVC
Top
Bottom
Ft.
in. in.
Top
Bottom
Ft.
in. in.
10. SANDIGRAVEL PACK:
Depth
Size Material
Top 33.0
Bottom 50.0
Ft. 20-40 FINE SILICA SAND
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING
LOG
Top
Bottom
Formation Description
0.0
/ 5.0
RED SILTY SANDY CLAY
5.0
/ 17.0
TAN SILTY SANDY CLAY
17.0
/ 28.0
TAN SANDY CLAY
28.0
/ 50.0
TAN/WHITE SAND
/
a 'E
12. REMARKS:
RFNTONITE
SEAL FROM
30.0
TO 33.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
C 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
E D HAS BEEIN PROVIDED WELL OWNER.
/28/12
SIGNATURE OF CERTIFIED WELL CONTRACEDTE T> ENRO
BRIAN THOMAS
PRINTED NAME OF PERSON CONSTRUCTING THI LO 2 2012

iwn
1. WELL CONTRACTOR:
BRIAN THOMAS .
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
70( 4 ) 872-7686
Area code Phone number
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2581
41 o.J .')
-z U � ,
d. TOP OF CASING IS 2.5 FT. Above Land Surface`
'Top of casing terminated atfor 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/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top 0.0 Bottom • 35.0 Ft. 2 INCH SCH 40 PVC
OTHER ASSOCIATED PERMIT#(ir applicable) : Top Bottom Ft.
SITE WELL ID #(if applicable) 8W<3� : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 02/21/12
4. WELL LOCATION:.
173 CSX DRIVE 28345
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY; HAMLET COUNTY RICHMOND
TOPOGRAPHIC / LAND SETTING: (check appropriate box).
❑ Slope ❑Valley ❑ Flat []Ridge ❑ Other
LATITUDE " DMS OR DID
LONGITUDE o"DMS OR DD
Latitudenongitude source: BPS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GAS)
5. FACILITY (Name of the business where the well is located.)
CSX HAMLET YARD WWTP
N/A
Facility Name
Facility ID# (if applicable)
173 CSX DRIVE
Street Address
HAMLET
NC
28345
City or Town
State
Zip Code
CSX TRANSPORTATION, INC
Contact Name
351 THORNTON ROAD SUITE 125
Mailing Address
LITHIA SPRINGS
GA
30122
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 50.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: 44.0 FT.
(Use "+" if Above Top of Casing)
8. GROUT:
Depth
Material Method
Top 0.0
Bottom 30.0
Ft.
PORTIANDSENTONITE SLURRY
Top
Bottom
Ft.
Top
Bottom
Ft.
: 9. SCREEN:
Depth
Diameter Slot Size Material
Top 35.0
Bottom 50.0
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 33.0
Bottom 50.0
Ft.
2040 FINE SILICA SAND
Top
Bottom
Ft.
: Top
Bottom
Ft.
11. DRILLING
LOG
Top
Bottom
Formation Description
0.0
/ 5.0
RED SILTY SANDY CLAY
5.0
/ 17.0
TAN SILTY SANDY CLAY
17.0
/ 28.0
TAN SANDY CLAY
28.0
/ 50.0
TANIWHITE SAND
tniGTt?li;�tSOn s^tv.�1�"' -
12. REMARKS:
RFNTONITF SEAL FROM 30.0 TO 33 n FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
ECORD HAS BEEN.PROVIDb . THE WELL OWNER.
BRIAN THOMAS APR- 0 211012
PRINTED NAME OF PERSON CONSTRUCTING THE WELL _U
Form GW-1b
Quality ; Information ProcesstngY_ Rev. 2/09

-off
1. WELL CONTRACTOR:
BRIAN THOMAS
r�
NONRESIDENTIAL q
ONRESIDENTIA�L WELL CONSTRUCTION RECORD � -i �' (� 0
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL.CONTRACTOR CERTIFICATION # 2581
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
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)Mw-4J
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 02/20/12
4. WELL LOCATION:
173 CSX DRIVE 28345 -
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: HAMLET COUNTY RICHMOND
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope []Valley ❑Flat ❑Ridge ❑Other
LATITUDE _°_' "DMS OR DD
LONGITUDE _°_' " DMS OR DD
Latitude/longitude source: BPS Qfopographic map
(location of well must be shown on a USGS topo map andattached to.
this form if not using GPSJ
5. FACILITY (Name of the business where the well is located.)
CSX HAMLET YARD WWTP
N/A
Facility Name
Facility ID# (if applicable)
173 CSX DRIVE
Street Address
HAMLET
NC
28345
City or Town
State
Zip Code
CSX TRANSPORTATION, INC
Contact Name
351 THORNTON ROAD SUITE 125
Mailing Address
LITHIA SPRINGS
GA
30122
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 55.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: 45.0
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 2.5 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
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 40.0
Ft.
2 INCH SCH 40 PVC
Top
Bottom
Ft.
Top
Bottom
Ft.
: 8. GROUT:
Depth
Material Method
Top 0.0
Bottom 35.0
Ft.
PORTLANDBENTONITE SLURRY
: Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top 40.0
Bottom 55.0
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 38.0
Bottom 55.0
Ft.
20-40 FINE SILICA SAND
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top
Bottom
Formation Description
0.0 /
6.0
RED SILTY SANDY CLAY
6.0 /
20.0
TAN SILTY SANDY CLAY
20.0 /
37.0
TAN SANDY CLAY
37.0 /
55.0
TAN/WHITE SAND
12. REMARKS:
BENTONITE SEAL FROM 35.0 TO 38.0 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
�EGORDPROM D TO THE WELL OWNER.
NO 02/28/12
C F WELL CONTRAC �_���
_FT. BRIAN THOMAS
PRINTED NAME OF PERSON CONSTRUCTING THE Vok 02,
2012
�y ,{�tiI_'ryra�ro

sa
�' ✓� NONRESIDENTIAL
� j D
1 r ONRESIDENTIAL WELL CONSTRUCTION RECORD
�✓., Ob North Carolina Department of Environment and Natural Resources- Division of Water Quality
P Q tY i1
'��,• WELL CONTRACTOR CERTIFICATION # 2581
1. WELL CONTRACTOR:
BRIAN THOMAS
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
7( 04 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(Kapplicable)
SITE WELL ID #(if applicable) MW-52
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 02/20/12
4. WELL LOCATION:
173 CSX DRIVE 28345
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: HAMLET COUNTY RICHMOND
TOPOGRAPHIC I LAND SETTING: (check appropriate box)
❑Slope ❑Valley []Flat []Ridge ❑Other
LATITUDE _' " DMS OR DD
LONGITUDE _°_' " DMS OR DD
Latitudefiongitude source: [I;PS pfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.)
CSX HAMLET YARD WWTP
N/A
Facility Name
Facility ID# (if applicable)
173 CSX DRIVE
Street Address
HAMLET
NC
28345
City or Town
State
Zip, Code
CSX TRANSPORTATION, INC
Contact Name
351 THORNTON ROAD SUITE 125
Mailing Address
LITHIA SPRINGS
GA
30122
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 60.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Dv
c. WATER LEVEL Below Top of Casing: 51.0 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 2.5 FT. Above Land Surface`
`Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 29 .0118.
: e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type NIA Amount NIA
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 45.0
Ft. 2 INCH SCH 40 PVC
Top
Bottom
Ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material Method
Top 0.0
Bottom 40.0
Ft.
PORTLAND13ENTONITE SLURRY
Top
Bottom
Ft.
Top
Bottom
Ft.
: 9. SCREEN:
Depth
Diameter
Slot Size Material
Top 45.0
Bottom 60.0
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 43.0
Bottom 60.0
Ft.
20-40 FINE SILICA SAND
Top
Bottom
Ft.
Top
Bottom
Ft.
I I- DRILLING LOG
Top
Bottom
Formation Description
0.0 /
8.0
RED SILTY SANDY CLAY
8.0 /
19.0
TAN SILTY SANDY CLAY
19.0 /
32.0
TAN SANDY CLAY
32.0 /
60.0
TANNVHITE SAND
`rye"
jam:.
12. REMARKS:
BENTONITE SEAL FROM 40.0 TO 43.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
CAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
CORD HAS BEEN PLk�ROVID THE WELL OWNER.
'SIGNATURE OF CERTIFIED WELL CONTRACTOR �I
BRIAN THOMAS _AOR 2 202,
PRINTED NAME OF PERSON CONSTRUCTING THE WEL
MA1
Form GW-1 b
Rev. 2/09

t+�
NONRESIDENTIAL WELL CONSTRUCTION RECORD
17 �Q North Carolina Department of Environment and Natural Resources- Division of Water Quality U L:
WELL CONTRACTOR CERTIFICATION #
2581
1. WELL CONTRACTOR:
: d. TOP OF CASING IS 2.5 FT. Above Land Surface`
BRIAN THOMAS .
'Top of casing terminated at/or below land surface may require
Well Contractor (Individual) Name
a variance in accordance with 15A NCAC 2C .0118.
GEOLOGIC EXPLORATION, INC
: e. YIELD (gpm): N/A METHOD OF TEST N/A
Well Contractor Company Name
176 COMMERCE BLVD
f. DISINFECTION: Type N/A Amount N/A
Street Address
; g. WATER ZONES (depth):
STATESVILLE NC 28625
: Top Bottom Top Bottom
City or Town State Zip Code
; Top Bottom Top Bottom
70( 4 ) 872-7686
: 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 35.0 Ft. 2 INCH SCH 40 PVC
OTHER ASSOCIATED PERMIT ap cable)
: Top Bottom Ft.
SITE WELL ID #(it applicable) (a/
:Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring C✓ Municipal/Public ❑
: 8. GROUT: Depth Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Top 0.0 Bottom 30.0 Ft. PORTUNDBEW0141TE SLURRY
irrigation❑ Other ❑ (list use)
: Top Bottom Ft.
DATE DRILLED 02/21/12
: Top Bottom Ft.
4. WELL LOCATION:
: 9. SCREEN: Depth Diameter Slot Size Material
173 CSX DRIVE 28345
; Top 35.0 Bottom 50.0 Ft. 2.0 in. .010 in. PVC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
;Top Bottom Ft. in. in.
CITY: HAMLET COUNTY RICHMOND
: Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
10. SAND/GRAVEL PACK:
LATITUDE "DMS OR DD
Depth Size Material
_°_'
Top 33.0 Bottom 50.0 Ft. 2040 FINE SILICA SAND
LONGITUDE _°_' " DMS OR DID
: Top Bottom Ft.
.Latitude/longitude source: DSPS Uopographic map
Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
11. DRILLING LOG
5. FACILITY (Name of the business where the well is located.)
Top Bottom Formation Description
CSX HAMLET YARD WWTP N/A
0.0 / 7.0 RED SILTY SANDY CLAY
Facility Name Facility ID# (if applicable)
7.0 / 19.0 TAN SILTY SANDY CLAY
173 CSX DRIVE
19.0 / 33.0 TAN SANDY CLAY
Street.Address
33.0 / 50.0 TAN/WHITE SAND
HAMLET NC 28345
City or Town State Zip Code
CSX TRANSPORTATION, INC
Contact Name
351 THORNTON ROAD SUITE 125
/ r
Mailing Address
LITHIA SPRINGS GA 30122
100" r,�rfCr�
City or Town State Zip Code
12. REMARKS:
BENTONITE SEAL FROM 30.0 TO 33.0 FEET
Area code Phone number
6. WELL DETAILS: HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
NCAC 2C, WELL CONST ON STANDARDS, AND THAT A COPY OF THIS
a. TOTAL DEPTH: 50.0 FEET /
• RE = OVUCITHE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q�
: 02/28/12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: 42.0 FT.
gRIAN THOMAS ��������
(Use "+" if Above Top of Casing)
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
APR 0 2.2012
Form GW-1 b
�ubmlt within 30 days'ofcompletlon to bl�Islon of Water Quality, ]nforma41on Processing,
. Rev. 2/09
617 MailtService Center, Raleigh, NC 27699 16a; Phone [phone] ; DWO
, t , t _

• ra „5T�4 .
,VYELL ABANDONMENT RECORD
North Carolina Department of Environment and Natuml Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION
1. WELL CONTRACTOR:
MIKE MCCONAHEY
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC.
Well Contractor Company Name
STREETADDRESS 176 COMMERCE BLVD.
STATESVILLE NC 28625
City or Town State Zip Code
7( 04 ) - 872-7686
Area code - Phone number
2. WELL INFORMATION: s- -._ -
SITE WELL ID#(ifapplicabIr),iHW-6- -
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (ifapplicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use): 0 Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery ❑ Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
rt �Ir,�%iotaa
COUNTY'". QUADRANGLE NAME
N1iARESTTO_WN. HAML-ET--
173-CSXDRIVE 28345
(SttcevRoad Name, Number, Community; Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
i
❑ Slope ❑ Valley ❑ Flat O Ridge ❑ Other
(Check appropriate setting)
LATITUDE May be in degrees,
—... mina cs, seconds, or in a
decimal format
LONGITUDE
] atitude/longitude source: ❑ GPS ❑ Topograpltic map
(Location of -well must be shown on a.USGS topo map and
attached to ddsform if not usingOPS)
4a. FACILITY. The name ofthe business where the well is located. Complete 42L and4b.
(Ifa residential well, skip 4a; complete 4b, well owner.infnmtation only,)
FACILITY ED #(if applicable)
NAME OF FACILITY CSX
STREETADDR.ESS 173 CSX DRIVE
HAMLET NC 28345'
City or Town State Zip Code
4b. CONTACT PERSONIWELL OWNER:
NAME CSX
STREET ADDRESS173CSXDRIVE HAMLET.NG28W
6. WELL DETAILS:
a. Total Depth: 58.0 ft. Diameter. 2.0 in.
b. Water Level (Below Measuring Point): ft.
Measuring point is ft. above land surface.
6. CASING:
a Casing Depth (if known):
b. Casing Removed:
Length Diameter
N/A & in.
�K, ft. in.
7. DISINFECTION: NIA
(Amount of 65%-75% calcium hypochlorite used)
& SEALING MATERIAL:
Neat Cement Send Cement
Cement — lb.
'Water— gal-
Bentoriite
Be atonite -lb.
Type: © Slurry []Pellets
Water gal.
Cement— lb.
Water"' gal.
Other
Type material PORTLAND BENTONITE SLURRY
Amount 9.5 GALLONS
9, EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
VIA TREMIE PIPE M! PORTLAND RENTONITE__
SLURRY
10, WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsuscd.
11, DATE WELL ABANDONED W5/09_.h
i DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH - CAC 2C, WELL CONSTRUCP(Oi5MAMM'�ND THAT A COPY OF
7RDS BEEN PROVIDED TO THE WELL OWNER
10/01 /09
crr_iva rttup nFa .uTrt rY n WF,r.LCON7TtA�#OR DATE
SIGNATURE OF PRIVATE WELL 6WNERABANDONING THE WELL DATE
(The private well ownermuA be an individual who pMonally abandons U-4wr residential well
in accordance with 15A NCAC 2C .0T 13.)
MIKE MCCONAHEY
PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn: Information Management, 1617 Mail Service Center —Raleigh, NC 27699-1617, Phone No. (919) 733-70I5 cat 568. Rev. 5/06