391952_Well Construction - GW1_20110316

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) MW-2
3. WELL USE (Check One Box) Monitoring d Municipal/Public D
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
IrrigationD Other 0 (list use)
DATE DRILLED 02/21/11
4. WELL LOCATION:
4420 HIGHWAY 74 EAST 28174
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WINGATE COUNTY UNION
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge 00ther
LATITUDE " DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: OGPS 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.)
WINGATE FOOD MART N/A
Facility Name Facility ID# (if applicable)
4420 HIGHWAY 74 EAST
Street Address
WINGATE NC 28174
City or Town State Zip Code
SHRI NATH
Contact Name
4420 HIGHWAY 74 EAST
Mailing Address
WINGATE
City or Town
NC 28174
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 24.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p/
c. WATER LEVEL Below Top of Casing: 5.0 FT.
(Use "+" if Above Top of Casing)
ubmit°will
17 Mall Service`
9
0
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
Top Bottom Top
Top Bottom Top
7. CASING: Depth
Top 0.0 Bottom 4.0
Top Bottom
Top Bottom
8. GROUT: Depth
Top 0.0 Bottom 3.0
Top Bottom
Top Bottom
Bottom
Bottom
Bottom
Thickness/
Diameter Weight Material
Ft. 2 INCH SCH 4o PVC
Ft.
Ft.
Material
Ft. PORTLAND BENTONITE
Ft.
Ft.
9. SCREEN: Depth Diameter Slot Size
Top 4.0 Bottom 24.0 Ft. 2.0
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Top 3.5 Bottom 24.0 Ft. 20-40
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0.0
1.0
3.0
15.0
1.0
3.0
15.0
24.0
Ft.
Ft.
Method
SLURRY
Material
in. .010 in. PVC
in. in.
in. in.
Size Material
FINE SILICA SAND
Formation Description
CONCRETE
GRAY/BROWN CLAY
BROWN ROCK
GRAY/WHITE ROCK
12. REMARKS:
BENTONITE SEAL FROM 3.0 TO 3.5 FEET
I DO HEREBY CERT
15A NCAC 2C, W
RECORD HAS
H T THI ELL WAS CONSTRUCTED IN ACCORDANCE WITH
S • NfttEDS, AND THAT A COPY OF THIS
L WNER.
SIGNATURE OFCERTIFI D
NICHOLAS HAYES
02/28/11
CON RACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING
THE
WELL LLU I� D F9®�f
E
ater Quality
919).8Q7.630Q,
MAR �Form.GW-1b
Rev. 2%091
Information Processing Unit
DWQ/BOG