393683_Well Construction - GW1_20110509

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2580
1. WELL CONTRACTOR:
JASON MANTAK
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC
City or Town State
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
28625
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-1
3. WELL USE (Check One Box) Monitoring @f Municipal/Public ❑'
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 04/04/11
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 ❑Vallev ID Flat ❑Ridge ❑Other
LATITUDE
LONGITUDE
" DMS OR
" DMS OR
DD
DD
Latitude/longitude source: EGPS Diopographic 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
NC 28110
State Zip Code
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: 20.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: 13.0
(Use "+" if Above Top of Casing)
NO q/
FT.
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•
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
WATER ZONES (depth):
7. CASING: Depth Diameter
Top 0.0 Bottom 10.0 Ft. 2 INCH
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 3.0
Thickness/
Weight Material
SCH 40 PVC
Ft. PORTLAND BENTONITE
Top Bottom Ft.
Top Bottom Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 10.0 Bottom 20.0 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 8.0 Bottom 20.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
FINE SILICA SAND
Formation Description
0.0 / 3.0 RED CLAY
3.0 / 20.0 TAN MUDSTONE
/
12. REMARKS:
BENTONITE SEAL FROM 3 0 TO 8.0 FEET
MAY - 9 LU1l
E.lt�rrnatinn Processing Unit
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL W
15A NCAC 2C, WELL CONSTRU
RECORD a BEEN PROVID
ONSTRUCTED IN ACCORDANCE WITH
ARDS, AND THAT A COPY OF THIS
LL OWNER.
04/11/11
SIGNAT "" E OF CERTIFIED WELL CONTRACTOR r.DATE
:
JASO61 MANTAK
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -, Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09