394761_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
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#(f applicable)
SITE WELL ID #(if applicable) MW-14
3. WELL USE (Check One Box) Monitoring [1 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05/16/11
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 ID Flat ❑Ridge ❑Other
LATITUDE " DMS OR
LONGITUDE " " DMS OR
Latitude/longitude source: IJ3PS Ofopographic 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.)
DD
DD
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
City or Town
NC 28110
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 33.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q/
c. WATER LEVEL Below Top of Casing: 20.0 FT.
(Use "+" if Above Top of Casing)
' { �^ awru..b ar��ra3,s++,y�q"4-. t',. ^,st
ubrnttwithin 30 days of completion toh Divis�ton.ofWater Quay,
1617Ma.ul Service Center Raleigh, -}NC 27699 161, Phone (919) 807(6300i
3`
7 dA v \J Y.
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 23.0 Ft. 2 INCH . "SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 17.0 Ft. PORTLAND BENTONITE
Top Bottom Ft.
Top Bottom Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 23.0 Bottom 33.0 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 21.0 Bottom 33.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0
5.0
12.0
30.0
5.0
12.0
30.0
33.0
FINE SILICA SAND
Formation Description
RED CLAY
BROWN CLAYEY SILT
BROWN ROCK
GRAY/WHITE ROCK
JuN 0 9 2011
Information Processing Unit
UWGVBOG
12. REMARKS:
BENTONITE SEAL FROM 17.0 TO 21.0 FEET
I DO HER
15A NC
RECO
SIGNATU OF CERTIF
NICHOLAS HAYES
LL WAS CONSTRUCTED IN ACCORDANCE WITH
ANDARDS, AND THAT A COPY OF THIS
LL OWNER.
05/26/11
WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09