394766_Well Construction - GW1_20110609

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2452
1. WELL CONTRACTOR:
JERRY WATKINS
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
NC 28625
State Zip Code
OTHER ASSOCIATED PERMIT#(f applicable)
SITE WELL ID #(if applicable) B-17
3. WELL USE (Check One Box) Monitoring 1 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05/17/11 & 05/24/11
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 ❑ Other
LATITUDE
LONGITUDE
" DMS OR DD
" DMS OR DD
Latitude/longitude source: BPS Dropographic 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
City or Town
NC 28110
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 55.0
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing: DRY FT.
(Use "+" if Above Top of Casing)
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1 Phone:
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):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top Bottom
Top Bottom
Top Bottom
Ft.
Ft.
Ft.
Material Method
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0.0 / 7.0
7.0 / 12.0
12.0 / 17.0
Ft.
Ft.
Ft.
Size Material
Formation Description
RED CLAYEY SILT
BROWN ROCK
WHITE/GRAY ROCK
17.0 / 26.0 BROWN ROCK
26.0 / 45.0 WHITE/GRAY ROCK
45.0 / 55.0 ROCK
/
12. REMARKS:
ROCK HAMMER BORING - DRY
RECEI{ d P
D
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1011
tntonnati nn Processing Unit
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS EN PROVIDED TO THE WELL OWNER.
4441 a(�, 05/26/11
TRACTOR DATE
SIGNATUR�OF C TIFIE
JERRY WATKINS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ter uuail,
9) 807-63.
Form GW-1 b
Rev. 2/09

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