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HomeMy WebLinkAbout398187_Well Construction - GW1_20110923NONRESIDENTIAL 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) sy•3` w syxas.&;k..si-`1�.. l Submit wlthmy301days of completlon�to fiDl�lslon=ofSWater (,tuaii ``,#-""�uaw�`€.pra ;F.•wr^ z.6 Center letg27699 .e+af a r-+,�w • a P"� e`,$ "`ne c 3.rev€ 5•. cr*> 161{7�Ma i ery cenRahh NC 161 Phtlne 4 (919)�807 3i 398117 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