393659_Well Construction - GW1_20110509

NON ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
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
State
28625
Zip Code
OTHER ASSOCIATED PERMIT#Qt applicable)
SITE WELL ID #(if applicable) AS-1 A
3. WELL USE (Check One Box) Monitoring V Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
IrrigationE Other ❑ (list use)
DATE DRILLED 04/04/11 - 04/05/11
4. WELL LOCATION:
130 NORTH SUTHERLAND AVENUE 28110
(Street Name, Numbers, Community, Subdivision, Lot No„ Parcel, Zip Code)
CITY: MONROE COUNTY UNION
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Vallev ❑Flat ❑Ridge ❑Other
LATITUDE " DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: I= PS [(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.)
NCDOT FACILITY N/A
Facility Name Facility ID# (if applicable)
130 NORTH SUTHERLAND AVENUE
Street Address
MONROE
City or Town
NC 28110
State Zip Code
NCDOT - PROFESSIONAL SERVICES MGT UNIT
Contact Name
4809 BERYL ROAD
Mailing Address
RALEIGH
City or Town
( 919 ) 250-3004
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
35.0 FEET
NC 27606
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [if
c. WATER LEVEL Below Top of Casing: 10.5 FT.
(Use "+" if Above Top of Casing)
er6
a a
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
Top 3.0 Bottom 20.0
Top Bottom
Top Bottom
Material
Ft. PORTLAND BENTONITE
Ft.
Ft.
Method
SLURRY
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
Top 23.0 Bottom 35.0
Top
Top
Bottom
Bottom
11. DRILLING LOG
Top Bottom
0.0
8.0
29.0
8.0
29.0
35.0
12. REMARKS:
BENTONITE SEAL FROM 20 0 TO 23.0 FEET
Size Material
Ft. 20-40
Ft.
Ft.
FINE SILICA SAND
Formation Description
BROWN/RED SILTY CLAY
PARTIALLY WEATHERED ROCK
GRAY SLATE
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oco
I DO
15A
R
CTED IN ACCORDANCE WITH
THAT A COPY OF THIS
SIGNATURE OF CERTIFIED WELL CONTRACTOR
JAMES HESS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days ofcompletion to: Division of Water Quality Information Processing,
1617 Mail Service Center,: Raleigh. NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09