387149_Well Construction - GW1_20100928

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envu onment 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) BR-21
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring E Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 09/15/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
COUNTY MECKLENBURG
1000 SOUTH CEDAR STREET 28208
(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 u1 degrees,
minutes seconds or
in a decimal format
❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form rf not using GPS)
4 FACILITY- is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY BEAZER PROPERTY
STREET ADDRESS 1000 SOUTH CEDAR STREET
CHARLOTTE
NC 28208
City or Town State
CONTACT PERSON CLARKSON STREET, LLC
Zip Code
MAILING ADDRESS 401 SOUTH TRYON STREET
CHARLOTTE NC
28202
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 40 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 35 0 FT
(Use "+" if Above Top of Casing)
13
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 Weight Material
From 0 0 To 30 0 Ft 2 INCH SG4U PVC
From To Ft
From To Ft
7 GROUT Depth Matenal Method
From To Ft
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 30 0 To 40 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 28 0 To 40 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 5 0 TAN SILTY CLAY
5 0 15 0 TAN ROCK
15 0 40 0 TAN/BROWN SANDSTONE
11 REMARKS
TEMPORARY WELL - WELL ABANDONED AFTER SAMPLING
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCA 2C WELL CONSTRUCTION ST ARDS AND THAT A COPY OF THIS
RECO' r AS ; EEN PROV JED TO THE n, L OWNER
it itV _ — 09/20/10
Sl?i`'� TURE ERTIFIED WELL CONTRACTOR DATE
JOHNNY BURR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days Attn Information MgtREC I V i W_1b
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No [phone] ext 568 ev /05
SEP 2 R 2n1p
Informarn, c ,

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