386779_Well Construction - GW1_20100827

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natut al Resources- Division of Water Quality
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-20
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 08/09/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE COUNTY MECKLENBURG
6020 WILKINSON BLVD 28208
(Street Name, Numbers, Community, Subdivision, Lot No Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑Valley ❑ Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source ❑GPS ❑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 FMR MARATHON GAS STATION
STREET ADDRESS 6020 WILKINSON BLVD
CHARLOTTE
NC 28208
City or Town State Zip Code
CONTACT PERSON VIJAY KAVURI
MAILING ADDRESS 6020 WILKINSON BLVD
CHARLOTTE NC 28208
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 30 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 20 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 with 15A NCAC 2C 0118
e YIELD (gpm) NA' 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 Wg ia lit Material
From 0 0 To 15 0 Ft 2 INCH SCH'4o PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 0 To 11 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 15 0 To 30 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 13 0 To 30 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 0 5 ASPHALT
0.5 10 GRAVEL
1 0 10,0 RED/BROWN CLAY
10 0 30 0 TAN SILTY CLAY
11 REMARKS
BENTONITE SEAL FROM 11 0 TO 13 0 FT
I DO HE-; . CE'�'TIFY THAT ' IS WELL W Yf ONSTRUCTED IN ACCORD N9E,WIT
15A NC •. •.C_t ---' '"UCTION . ;,,rFit • : DS N T,+A� PY,OF�`THI .
RECORn�p"1TB`EN'.IDEDTOTHEv�� Ii zy`-,�Ctit rye'
/11D
SIGNATURE OF CERTIFIED WELL CONTRig0 2
JOHNNY BURR
irf-Irmattnn Processing Unit
PRINTED NAME OF PERSON CONSTRUCTINGokiE;WEt4U
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

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