393662_Well Construction - GW1_20110509

NON RESIDENTIAL 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) MW-12
3. WELL USE (Check One Box) Monitoring Ni Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other 0 (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 0Vallev ❑Flat ❑Ridge ❑Other
LATITUDE " DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: (BPS Qfopographic 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 NC 28110
City or Town 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:
30.0 FEET
NC 27606
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO V
c. WATER LEVEL Below Top of Casing: 11.5 FT.
(Use "+" if Above Top of Casing)
3 6 62
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
7. CASING: Depth Diameter
Top 0.0 Bottom 10.0 Ft. 2 INCH
Top Bottom Ft.
Top Bottom Ft.
Thickness/
Weight Material
SCH 40 PVC
8. GROUT: Depth Material
Top 0.0 Bottom 5.0 Ft. PORTLAND BENTONITE
Top Bottom Ft.
Top Bottom Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 10.0 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
Top 8.0 Bottom 30.0
Top
Top
Size Material
Ft. 20-40
Bottom Ft.
Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 /
8.0 /
22.0 /
8.0
22.0
30.0
12. REMARKS:
BENTONITE SEAL FROM 5.0 TO 8.0 FEET
FINE SILICA SAID
Formation Des r{ption� s'Og
BROWN SILTY CLAY pcoO00
GRAY WEATHERcE (1O} t"
GRAY SLATE \C O J
I DO HEREBY,
15A NCAC
RECO
IN ACCORDANCE WITH
T A COPY OF THIS
04/07/11
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.:-
1617 Mail Service Center, -Raleigh, NC 27699 161,'Phone : [phone]
Information Processin
Form GW-lb
Rev. 2/09