398945_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
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#('If applicable)
SITE WELL ID #(if applicable) SVE-5
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection ❑
Irrigation❑ Other 0 (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: BPS [Topographic 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 28105
State Zip Code
Contact Name
420 SOUTH KEELER AVENUE
Mailing Address
BARTLESVILLE
City or Town
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 15.0 FEET
b. DOES WELL REPLACE EXISTING WELL?
OK 74006
State Zip Code
YES NOq/
c. WATER LEVEL Below Top of Casing: 13.0
(Use "+" if Above Top of Casing)
FT.
Imlt within 30 days of comprletion toA DivisiPn oof
7)Mail Service Center, Raleigh, NC 27699 161 hone.
3 8545
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
N/A
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
Bottom
Bottom
Bottom
Thickness/
7. CASING: Depth Diameter Weight
Top 0.0 Bottom 5.0 Ft. 4 INCH SCH 40
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 1.0 Ft. PORTIAND BENTONITE
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top 5.0 Bottom 15.0 Ft. 4.0
Top Bottom Ft.
Top Bottom Ft.
Material
PVC
Method
SLURRY
Slot Size Material
in. .010 in. PVC
in. in.
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
FINE SILICA SAND
Formation Description
0.0 / 5.0 ORANGE SILTY SAND
5.0 / 15.0 BROWN/ORANGE SILTY CLAY
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12. REMARKS:
BENTONITE SEAL FROM 1.0 TO 3.0 FEET
I DO HEREEBBYYY CERTIFYTHATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
R 15A
FySaWELL EEN P1�NVIDESTR C71?IOTHE WEN
ERDS,R AND THAT A COPY OF THIS
ft
k
09/29/11
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
MARK GETTYS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ormation
Form GW-lb
Rev. 2/09