398189_Well Construction - GW1_20110923

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3098
1. WELL CONTRACTOR:
JOHNNY BURR
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Narne
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
( 704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) PMW-7
3. WELL USE (Check One Box) Monitoring Ni Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 09/07/11 - 09/08/11
4. WELL LOCATION:
3012 MASON STREET. 28110
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: MONROE COUNTY UNION
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat
❑ Ridge 0 Other
LATITUDE " DMS OR DD
LONGITUC " DMS OR DD
Latitude/longitude source: D3PS DTopographic 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.)
COOPER HAND TOOLS N/A
Facility Name Facility ID# (if applicable)
3012 MASON STREET
Street Address
MONROE NC 28110
City or Town State Zip Code
COOPER HAND TOOLS
Contact Name
3012 MASON STREET
Mailing Address
MONROE NC 28110
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 40.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Lv
c. WATER LEVEL Below Top of Casing: 10.0 FT.
(Use "+" if Above Top of Casing)
ul rnit,wlthrn30 tlays of.comp etlon(to Div on o
617 Center, Raleigh, NC27699 161 Phone'
Marl Service
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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 30.0 Ft. 2 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 24.0 Ft. PORTLANOBENTONITE SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 30.0 Bottom 40.0 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 28.0 Bottom 40.0 Ft. 20-40 FINE SILICA SAND
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0.0 / 8.0 RED/BROWN CLAY
8.0 / 40.0 GRAY ROCK
/
/ SEP 2 :i rilti
/ �mlutrnaflori Processing Unit
/ L)VV(.)/13UG
12. REMARKS:
BENTONITE SEAL FROM 24.0 TO 28.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL
15A N2C ELL CON RUCTION S
RECI ' H'' : E ' • IDEDTO
S CONSTRUCTED IN ACCORDANCE WITH
DARDS, AND THAT A COPY OF THIS
LI
09/12/11
ATURE ' CERTIFIED WELL CONTRACTOR DATE
JOHNNY BURR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-lb
qfpcessrng Rev. 2/09