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HomeMy WebLinkAbout393688_Well Construction - GW1_20110509NONRESIDENTIAL 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 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) MW-6 3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑ Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0 Irrigation0 Other ❑ (list use) DATE DRILLED 04/05/11 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 " DMS OR DD LONGITUDE " DMS OR DD Latitude/longitude source: BPS Ofopographic 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 NC 28110 City or Town State Zip Code ( ) Area code Phone number 6. WELL DETAILS: a. TOTAL DEPTH: 35.0 FEET b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 57 c. WATER LEVEL Below Top of Casing: 28.0 FT. (Use "+" if Above Top of Casing) 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 25.0 Ft. 2 INCH scH 40 PVC Top Bottom Ft. Top Bottom Ft. 8. GROUT: Depth Material Method Top 0.0 Bottom 19.0 Ft. PORTLANDBENTONITE SLURRY Top Bottom Ft. Top Bottom Ft. 9. SCREEN: Depth Diameter Slot Size Material Top 25.0 Bottom 35.0 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 23.0 Bottom 35.0 Ft. 20-40 FINE SILICA SAND Top Bottom Ft. Top Bottom Ft. 11. DRILLING LOG Top Bottom 0.0 / 9.0 9.0 / 13.0 13.0 / 35.0 / Formation Description TAN CLAY TAN MUDSTONE GRAY ROCK 6 ``0, Evil--1) tl a ems, M n... N - MAZOi 12. REMARKS: Information rrut;b DWQ/BOG BENTONITE SEAL FROM 19.0 TO 23.0 FEET I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C ELL CONSTRUCT N ST N e `IS, AND THAT A COPY OF THIS RECORD HA EN PROVI� �7 H-fir,"L L OWNER. 04/11/11 SIGNATU OF CERTIFIED WELL CONTRACTOR DATE JASOMANTAK PRINTED NAME OF PERSON CONSTRUCTING THE WELL it Submit; within .30,days of completion to: Division of Water Quality :- Information Processing, 1617 Mail Service Center,; Raleigh, NC 27699-16.1, Phone;: (9.19) :807-6300 Form GW-1 b Rev. 2/09