393691_Well Construction - GW1_20110509

NON ONRESIDENTIAL 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-9
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 04/06/11
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
LONGITUDE " DMS OR
DD
DD
Latitude/longitude source: D3PS [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.)
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 NC 28110
City or Town State Zip Code
�)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 30.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO qi
c. WATER LEVEL Below Top of Casing: 15.0 FT.
(Use "+" if Above Top of Casing)
3) e�j 6 ,�
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 20.0 Ft. 2 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 14.0 Ft. PORTLANDBENTONITE SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 20.0 Bottom 30.0 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 18.0 Bottom 30.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
FINE SILICA SAND
11. DRILLING LOG
Top Bottom Formation Description
0.0 / 3.0 RED CLAY
3.0 / 6.0
6.0 / 30.0
RED MUDSTONE
TAN MUDSTONE
MAY - 9 2 011
INmmIntion Processing Unit
DWCt/t Uv
12. REMARKS:
BENTONITE SEAL FROM 14.0 TO 18 0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WA
15A NCAC 2• ELL CONSTRU
RECORD H't:EEN PROV
NSTRUCTED IN ACCORDANCE WITH
RDS, AND THAT A COPY OF THIS
L OWNER.
04/11/11
SIGNAT n E OF CERTIFIED WELL CONTRACTOR DATE
JASO 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;; NC27699-161 Phone°::[phone];
Form GW-1 b
Rev. 2/09