386034_Well Construction - GW1_20100803

NONRESIDENTIAL WELL CONSTRUCTION RECORD
Information Processing L,,
v u RECEIVEE'
AUG 0 3 2011J
North Carolina Department of Environment and Natural Resources- Division of Water Quality DWQ/BOG
WELL CONTRACTOR CERTIFICATION # 3098
1 WELL CONTRACTOR
JOHNNY BURR
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD
STATESVILLE NC
28625
City or Town State Zip Code
( 704 )- 872-7686
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) MW-13
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 07/08/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
5315 MONROE ROAD 28205
COUNTY MECKLENBURG
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑ Flat ❑ Ridge ❑ Other
(check appropnate box)
LATITUDE
LONGITUDE
Latitude/longitude source
May be in degrees,
minutes, seconds or
in a decimal format
❑GPS Li Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
4 FACILITY is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY A CLEANER
STREET ADDRESS 5315 MONROE ROAD
CHARLOTTE
NC 28205
City or Town State
CONTACT PERSON NCDENR
Zip Code
MAILING ADDRESS 601 OBERLIN ROAD
CHARLOTTE NC
28205
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 26 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
c WATER LEVEL Below Top of Casing 8 0 FT
(Use "+" if Above Top of Casing)
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 wth 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)
From To From To
From To From To
From To From To
6 CASING Thickness/
Depth Diameter We ia ht Material
From 0 0 To 6 0 Ft 2 INCH SCH 40 PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 0 To 3 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 6 0 To 26 0 Ft 2 0 in 010 in PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 4 0 To 26 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 10 0 RED/ORANGE SANDY CLAY
10 0 24 0 TAN SILTY CLAY
24 0 26 0 TAN WEATHERED ROCK
11 REMARKS
BENTONITE SEAL FROM 3 0 TO 4 0 FT
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL CONSTPWCTION STAND : DS AND THAT A COPY OF THIS
RECO 6 A ¢ TO THE W ,. WNER
-x'.
i tr%ri� 1. 07/12/10
SIfNATURE dF CERTIFIED WELL CONTkACTOR DATE
JOHNNY BURR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn Information Mgt ,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No [phone] ext 568
Form GW-lb
Rev 7/05