382192_Well Construction - GW1_20100331

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2581
1. WELL CONTRACTOR.
BRIAN THOMAS
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-10-D,S
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ® Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 03/01/10 - 03/03/10
Recovery ❑ Injection 0
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
9710 MONROE ROAD 28270
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
May be in degrees,
minutes, seconds or
in a decimal tonnat
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 JFR CLEANERS
STREET ADDRESS
CHARLOTTE NC 28270
9710 MONROE ROAD
City or Town State Zip Code
CONTACT PERSON NCDEHNR
MAILING ADDRESS 601 OBERLIN ROAD
RALEIGH NC 27605
City or Town State Zip Code
( )-
Area code - Phone number
5. WELL DETAILS
a TOTAL DEPTH
54 0/30 0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 17 0 FT
(Use "+" if Above Top of Casing)
3 -
2
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 Wg 1Q ht Material
From 0 0 To 49 0 Ft 1 INCH SCH a PVC
From 0 0 To 10 0 Ft 1 INCH SCH 40 PVC
From To Ft
7. GROUT Depth Material Method
From 0 0 To 5 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 49 0 To 54 0 Ft 1 0 in 010 in PVC
From 10 0 To 30 0 Ft 1 0 in 010 in PVC
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 47 0 To 54 0 Ft 20-40 FINE SILICA SAND
From 8 0 To 30 0 Ft 20-40 FINE SILICA SAND
From To Ft
10. DRILLING LOG
From To Formation Description
0 0 1 0 GRAVEL
1 0 12 0 RED SILTY CLAY
12 0 21 0 ORANGE SILTY CLAY
21 0 34 0 BROWN SILTY CLAY
34 0 54 0 TAN SILTY CLAY
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MAP, 3 1 2010
11 REMARKS Information Processing Unit
BENTONITE SEAL FROM 32 0 TO 47 0 FT1&/51l) T0A 0 FT
WITH
i sA CAC WELL CERTIFY THAT THIS WELL WAS COS, AND IN ACCORDANCEYOFTHIS
15A AC ,WELL CONSTRUCTION STA S, AND THAT A COPY OF THIS
REGO EETfPROVIDED TO T LL WNER
.%lit,G/L/h 03/04/10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
BRIAN THOMAS
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

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