382193_Well Construction - GW1_20100331

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envu onment 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
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-9-D,S
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 0 (list use)
DATE DRILLED 03/01/10 - 03/03/10
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION*
CITY CHARLOTTE COUNTY MECKLENBURG
9710 MONROE ROAD 28270
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑ Flat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE
LONGITUDE
Latttude/longitude source ❑GPS
May be in degrees,
minutes, seconds or
in a decimal tormat
❑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 Of applicable)
NAME OF FACILITY JFR CLEANERS
STREET ADDRESS 9710 MONROE ROAD
CHARLOTTE
NC 28270
City or Town State
CONTACT PERSON NCDEHNR
Zip Code
MAILING ADDRESS 601 OBERLIN ROAD
RALEIGH NC
27605
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH
52 0/30 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO El
c. WATER LEVEL Below Top of Casing 17 0 FT
(Use "+" if Above Top of Casing)
3�2
93
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 NIA
f DISINFECTION Type N/A Amount N/A
g WATER ZONES (depth)
From
From
From
6 CASING
To
To
To
Depth
From 0 0 To 47 0
From 0 0 To 10 0
From To
Ft
Ft
Ft
From
From
From
To
To
To
ee�� Thickness/
1 Diameter
SCll-Y40 Material
1 INCH
SCH 40 PVC
7 GROUT Depth Material
From 0 0 To 5 0 Ft Portland bentonite
From To Ft
From To Ft
8. SCREEN Depth Diameter
From 47 0 To 52 0 Ft 1 0 in
From 10 0 To 30 0 Ft 1 0 in
From To Ft in in
Method
SLURRY
Slot Size Material
010 in PVC
010 in PVC
9 SAND/GRAVEL PACK
Depth
From 45 0 To
From 8 0 To
From To
52 0
30 0
Ft
Ft
Ft
Size
20-40
20-40
Material
FINE SILICA SAND
FINE SILICA SAND
10. DRILLING LOG
From To Formation Description
0 0 1 0 GRAVEL
1 0 12 0 RED SILTY CLAY
12 0 21 0
21 0 34 0 BROWN SILTY CLAY
34 0
ORANGE SILTY CLAY
52 0 TAN SILTY=CLAYS X / ry - F)
MAP, 1 2010
Inform-IFL... n__ - -
n 4, V1111
f)W(1/Rnr_
11 REMARKS
BENTONITE SEAL FROM 32 0 TO 45 0 FT & 5 0 TO 8 0 FT
:Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
5A f1CAC WELL CONSTRUCTION STAN DS, AND THAT A COPY OF THIS
c _ sS BE60I.ROVIDED TO T L OWNER
i
SIGNATURE OF CERTIFIED WELL CONTRACTOR
BRIAN THOMAS
03/04/10
DATE
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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