386036_Well Construction - GW1_20100803

3 6 RECEIVED
NONRESIDENTIAL WELL CONSTRUCTION RECORD AUG ® 3 2010
North Carolina Department of Environment and Natural Resources- Division of Water Quality
Information Processing unit
WELL CONTRACTOR CERTIFICATION # 3098
1 WELL CONTRACTOR
JOHNNY BURR
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
STREET ADDRESS
STATESVILLE
176 COMMERCE BLVD
NC 28625
City or Town State Zip Code
( 704 )_ 872-7686
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(If applicable) MW-15-D, S
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ® 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 El CPS
May be in degrees,
minutes, seconds or
in a decimal format
❑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 55 0/22 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Fi
c WATER LEVEL Below Top of Casing 9 0 FT
(Use "+" if Above Top of Casing)
DWQ/BOG
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)
From To From To
From To From To
From To From To
6 CASING Thickness/
Depth Diameter We i lit Material
From 0 0 To 50 0 Ft 1 INCH SCR'40 PVC
From 0 0 To 7 0 Ft 1 INCH SCH 40 PVC
From To Ft
7 GROUT Depth Material Method
From 0 0 To 4 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 50 0 To 55 0 Ft 1 0 in 010 in PVC
From 7 0 To 22 0 Ft 1 0 in 010 in PVC
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 47 0 To 55 0 Ft 20-40 FINE SILICA SAND
From 5 0 To 22 0 Ft 20-40 FINE SILICA SAND
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 10 0 RED/ORANGE SANDY CLAY
10 0 28 0 TAN SILTY CLAY
28 0 55 0 TAN WEATHERED ROCK
11 REMARKS
BENTONITE SEAL FROM 25 0 TO 47 0 FT & 4 0 TO 5 0 FT
I DO HEBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC,.2C 1WELL CONST UCTION STAN o ;." DS AND THAT A COPY OF THIS
RECOIfD E '• .DEDTOTHE fSWNER \
( tia /" : �..�::Ax y .s-J 07112/10
SIGNATURE OF CERTIFIED WE CONTR' C • - 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