398946_Well Construction - GW1_20111021

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2345
1. WELL CONTRACTOR:
MARK GETTYS
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
(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) SVE 6
3. WELL USE (Check One Box) Monitoring vd Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 09/28/11
4. WELL LOCATION:
13024 EAST INDEPENDENCE BLVD 28105
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STALLINGS COUNTY UNION
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE "DMS OR DD
LONGITUDE ° " DMS OR DD
Latitude/longitude source: IDGPS Qfopographic 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.)
RMR - 2364 N/A
Facility Name Facility ID# (if applicable)
13024 EAST INDEPENDENCE BLVD
Street Address
STALLINGS
City or Town
CONOCO PHILLIPS
NC
State
28105
Zip Code
Contact Name
420 SOUTH KEELER AVENUE
Mailing Address
BARTLESVILLE
City or Town
OK 74006
State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 15.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Lif
c. WATER LEVEL Below Top of Casing: 13.0 FT.
(Use "+" if Above Top of Casing)
comp ptl.90,9
aletgh; NC,=276C
3989 6
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 0.0 Bottom 5.0 Ft. 4 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 1.0
Top Bottom
Top Bottom
Ft.
Ft.
Ft.
Material
PORTLAND BENTONITE
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 15.0 Ft. 4.0 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 3.0 Bottom 15.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 5.0
FINE SILICA SAND
Formation Description
ORANGE SILTY SAND
5.0 / 15.0 BROWN/ORANGE SILTY CLAY
/
UL; 21 2011
Proc'cl.rlrt Unit
12. REMARKS:
BENTONITE SEAL FROM 1.0 TO 3.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A y Fi1lS WELL C STRCTON STAN.' -.S, AND T T A COPY OF THIS
R EN P VIDE THE WELL'1 t
Noll
09/29/11
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
MARK GETTYS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ater uuai
919)'807-630
Form GW-1b
Rev. 2/09

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