383676_Well Construction - GW1_20100420

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2580
1. WELL CONTRACTOR:
JASON MANTAK
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-34
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ® Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 03/08/10
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY: MONROE COUNTY UNION
3000 HIGHWAY 74 EAST 28110
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ❑Flat ❑Ridge ❑ Other_
(check appropriate box)
LATITUDE • )
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: El 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 NORTON DOOR CONTROL
STREET ADDRESS 3000 HIGHWAY 74 EAST
MONROE NC 28110
City or Town State Zip Code
CONTACT PERSON NORTON DOOR CONTROL
MAILING ADDRESS 3000 HIGHWAY 74 EAST
MONROE NC 28110
City or Town State Zip Code
( )-
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 17.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ej
c. WATER LEVEL Below Top of Casing: 9.0 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 Weiqht Material
From 0.0 To 7.0 Ft. 2 INCH SCI-T40 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 7.0 To 17.0 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 5.0 To 17.0 Ft. 20-40 FINE SILICA SAND
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0.0 5.0 ORANGE CLAY
5.0 15.0 TAN MUDSTONE
15.0 17.0 GRAY ROCK
tVl CI' r*.0A p,_
AY 2
0 2010
inrorrnation Pr
cc
11. REMARKS: DVVQ/80 g Unit .
BENTONITE SEAL FROM 1.0 TO 5.0 FT.
I DO HEREBY CERTIFY THAT THIS WELL • AS CONSTRUCTED IN ACCORDANCE WITH
15A N C 2C, WELL CON •'" UC'41t.p. = ANDARDS, AND THAT A COPY OF THIS
RECO HAS BEEN-.'_rt,, G t,Igi pE WELL OWNER.
/,',' "".-- (' 4/15/10
SIG TURE OF CERTIFIED WELL CONTRACTOR DATE
ASON MANTAK
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-lb
Rev. 7/05

�9