393660_Well Construction - GW1_20110509

STATE,>„
NONRESIDENTIAL 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 28625
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) AS-3
3. WELL USE (Check One Box) Monitoring d 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 ❑Valley ❑Flat ❑Ridge DOther
LATITUDE "DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: D3PS EJtopographic 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 wherethe well is located.)
NCDOT FACILITY N/A
Facility Name Facility ID# (if applicable)
130 NORTH SUTHERLAND AVENUE
Street Address
MONROE
City or Town
NC
State
NCDOT - PROFESSIONAL SERVICES MGT UNIT
Contact Name
4809 BERYL ROAD
28110
Zip Code
Mailing Address
RALEIGH
City or Town
NC 27606
State
( 919 ) 250-3004
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 35.0 FEET
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 25.0 Ft. 2 INCH
Top Bottom Ft.
Top Bottom Ft.
6S 0
Material
SCH 40 PVC
8. GROUT: Depth Material Method
Top 3.0 Bottom 20.0 Ft. PORTLANDBENTONITE SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Top 25.0
Top
Top
Diameter Slot Size Material
Bottom 35.0 Ft. 2.0 in. .010 in. PVC
Bottom
Bottom
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 23.0 Bottom 35.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0
7.0
25.0
7.0
25.0
35.0
FINE SILICA SAND
Formation Description
BROWN/RED SILTY CLAY
PARTIALLY WEATHERED ROCK
GRAY SLATE
� c
information Processing Unit
Zip Code pWCl/SOS
12. REMARKS:
BENTONITE SEAL FROM 20.0 TO 23.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO al
c. WATER LEVEL Below Top of Casing: 16.0 FT.
(Use "+" if Above Top of Casing)
IDO HEREBY
15A NCAC
RECORD
RTIFY THAT THIS WELL WAS CONSTRU
ELL CON 0 DARDS, AN
PVI IO TH ELNER
IN ACCORDANCE WITH
AT A COPY OF THIS
04/07/11
GF ATURE OF CERTIFIED WELL CONTRACTOR DATE
JAMES HESS
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