398184_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 Name
176 COMMERCE BLVD
Street Address
STATESVILLE
City or Town
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(f applicable)
SITE WELL ID #(if applicable) PMW-2
NC
State
28625
Zip Code
3. WELL USE (Check One Box) Monitoring tl Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 09/07/11
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 oValley ❑ Flat ❑ Ridge ❑ Other
LATITUDE "DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: IJ3PS OTopographic 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
City or Town
COOPER HAND TOOLS
Contact Name
3012 MASON STREET
NC 28110
State Zip Code
Mailing Address
MONROE
City or Town
NC 28110
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 30.5 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p/
c. WATER LEVEL Below Top of Casing: 10.0 FT.
(Use "+" if Above Top of Casing)
Submit wlthln 30, da s of,comPletlon to
v ire xlf�7 A v� 4 v a V xtir R, Yiw
1617 MarIIIServiide Center Raleigh;NC 27699
tiR , a€ n tom. + .r w4' z.
d. TOP OF CASING IS 2.5 FT. Above Land Surface*
*Top of casing terminated'at/or°below landsurface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A -METHOD OF TEST
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
N/A
N/A
Thickness/
7. CASING: Depth Diameter .Weight
Top 0.0 Bottom 20.5 Ft. 2 INCH SCH 40
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 14.0 Ft. PORTLAND BENTONITE
Top Bottom Ft.
Top Bottom Ft.
Material
PVC
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 20.5 Bottom 30.5 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 18.0 Bottom 30.5 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
FINE SILICA SAND
Formation Description
0.0 / 5.0 RED CLAY
5.0 / 15.0 BROWN PARTIAL WEATHER ROCK
15.0 / 30.5 GRAY ROCK ,,�,
/-_�� 1
SEP
•If3.:71104,ion Proce5S141g
n\NO/BOG
12. REMARKS:
BENTONITE SEAL FROM 14.0 TO 18.0 FEET
IDOHEBY
15AN2C
RE
RTIFY THAT THIS WELL
ELL CON RUCTION S
DED TO
CONSTRUCTED IN ACCORDANCE WITH
ARD�S,,, AND THAT A COPY OF THIS
,40`/ M
09/12/11
NATURE • CERTIFIED WELL CONTRACTOR DATE
JOHNNY BURR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
er, Quali'
919),t07.-3b1
Form GW-1 b
Rev. 2/09