394762_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/kV applicable)
SITE WELL ID #(if applicable) MW-15
3. WELL USE (Check One Box) Monitoring Ne Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 05/17/11
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)
❑ SIope ❑ Valley ❑ Flat ❑ Ridge ❑ Other
LATITUDE " DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: J3PS propographic 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
3012 MASON STREET
Facility ID# (if applicable)
Street Address
MONROE NC 28110
City or Town State Zip Code
COOPER HAND TOOLS
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: 35.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO al
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
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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 25.0 Ft. 2 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 19.0
Ft. PORTLAND BENTONITE
Top Bottom Ft.
Top Bottom Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 25.0 Bottom 35.0 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 23.0 Bottom 35.0 Ft. 20-40 FINE SILICA SAND
Top
Top
Bottom Ft.
Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 5.0
5.0 / 9.0
9.0 / 18.0
18.0 / 35.0
Formation Description
RED CLAY
RED SILT
BROWN SILT
BROWN ROCK
R CEIVfD
JUN 0 9 2n11
irformdliurl Processing Unit
12. REMARKS: DWQ/g
BENTONITE SEAL FROM 19.0 TO 23.0 FEET
I DO H - ": ' ' TIFY . AT THI LL WAS CONSTRUCTED IN ACCORDANCE WITH
15A Nod, 11ir,� ��;."r.r.. T STANDARDS, AND THAT A COPY OF THIS
RE E WELL OWNER.
05/26/11
SIGNAT ' E OF CERT : D WELL CONTRACTOR DATE
NICHOLAS HAYES
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ormationwProcessin
Form GW-lb
Rev. 2/09