398187_Well Construction - GW1_20110923

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4121
1. WELL CONTRACTOR:
NICHOLAS HAYES
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#('rr applicable)
SITE WELL ID #(if applicable) PMW-4
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 08/31/11 - 09/01/11
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: IJPS pfopographic 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: 40.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q�
c. WATER LEVEL Below Top of Casing: 30.0 FT.
(Use "+" if Above Top of Casing)
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d. TOP OF CASING IS 2.5 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 30.0 Ft. 2 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material - Method
Top 0.0 Bottom 23.0 Ft. PORTLAND BENTONITE SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 30.0 Bottom 40.0 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 28.0 Bottom 40.0 Ft. 20-40 FINE SILICA SAND
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 10.0
10.0 / 15.0
15.0 / 40.0
/
/
Formation Description
TAN SILT
MUDSTONE
GRAY/WHITE ROCK
SEP 2 fi �f111
kiformatier
12. REMARKS:
BENTONITE SEAL FROM 23.0 TO 28.0 FEET
I DO HERE Y T Y TH CHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCA • NDARDS, AND THAT A COPY OF THIS
RECORe O ELL OWNER.
09/12/11
SIGNATUR OF CERTI I _,i► ELL ONTRACTOR DATE
NICHOLAS HAYES
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
nformation Processing,
Form GW-lb
Rev. 2/09