399004_Well Construction - GW1_20111021

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#('If applicable)
SITE WELL ID #(if applicable) PMW-1
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 09/22/11 - 09/23/11
4. WELL LOCATION:
3000 US HIGHWAY 74 EAST 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
LONGITUDE °
"DMS OR
" DMS OR
DD
DD
Latitude/longitude source: D3PS 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.)
NORTON DOOR CONTROL
N/A
Facility Name Facility ID# (if applicable)
3000 US HIGHWAY 74 EAST
Street Address
MONROE
City or Town
YALE SECURITY, INC
NC 28110
State Zip Code
Contact Name
3000 US HIGHWAY 74 EAST
Mailing Address
MONROE
City or Town
NC 28110
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO d
c. WATER LEVEL Below Top of Casing: 20.0
(Use "+" if Above Top of Casing)
�mttawlthln�30'days,of com
IMatliSenri a Center; Rafei
p)etlon4o'
9.9^1
FT.
d. TOP OF CASING IS 0.0 FT. Above Land Surface*
*Top of casing terminated.at/orbelow 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 15.0 Ft. 2 INCH SCH 40 PVC
Top 0.0 Bottom 15.0 Ft. 6 INCH SCH 40 PVC
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 10.0 Ft. PORTLAND BENTONITE SLURRY
Top • 0.0 Bottom 15.0 Ft. PORTLANDBENTONITE SLURRY
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 15.0 Bottom 25.0 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 13.0 Bottom 25.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0
13.0
20.0
22.0
13.0
20.0
22.0
25.0
12. REMARKS:
BENTONITE SEAL FROM 10 0 TO 13 0 FEET
FINE SILICA SAND
Formation Description
TAN SILT
GRAY/WHITE ROCK
BROWN SILT
GRAY/WHITE ROCK
UL: 21 2011
'Ionnat,On F'roc ssi•ng, Unit
UWQ/BOG
I DO HEREBY CE-. IFY HAT
15A NCAC 2C+NST'
RECORD Y JJ"• +
TWELL WAS CONSTRUCTED IN ACCORDANCE WITH
0 T .:. DARDS, AND THAT A COPY OF THIS
• L OWNER.
SIGNATURE t C 'T
NICHOLAS HAYES
09/23/11
LCI TRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
rocess!ng,
Form GW-lb
Rev. 2/09

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