386038_Well Construction - GW1_20100803

3 13 5 8 RECEIVED
NONRESIDENTIAL WELL CONSTRUCTION RECORD AUG 0 3 2010
North Carolina Department of Environment and Natural Resources- Division of Water Quality_
Processing Unit
DWQ/BOG
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
( 704 )- 872-7686
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) MW-6-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 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 07/12/10 - 07/13/10
Zip Code
TIME COMPLETED AM ❑ PM 0
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 0 Other
(check appropnate box)
LATITUDE
LONGITUDE
Latitude/longitude source
May be in degrees,
minutes, seconds or
in a decunal format
❑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 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
57 0/22 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing 14 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) N/A METHOD OF TEST N/A
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 52 0
From 0 0 To 7 0
From To
From To
From To
Thickness/
SCR 4O PVC ial
Ft 1 INCHer
Ft 1 INCH
From To Ft
7 GROUT
From 0 0
From
From
Depth
To 30
To
To
8. SCREEN Depth
From 52 0 To 57 0
SCH 40 PVC
Material
Ft Portland bentonite
Ft
Ft
Method
SLURRY
Diameter Slot Size Material
Ft 1 0 in 010 in PVC
From 7 0 To 22 0 Ft 1 0 in 010 in PVC
From To
9 SAND/GRAVEL PACK
Ft in in
Depth Size Material
From 50 0 To 57 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 1 0 GRAVEUASPHALT
1 0 13 0 RED SILTY CLAY
130
29 0
45 0
29 0
TAN SILTY CLAY
45 0 GRAY SILTY SANDY CLAY
57 0 PARTIALLY WEATHERED ROCK
11 REMARKS
BENTONITE SEAL FROM 24 0 TO 50 0 FT & 3 0 TO 5 0 FT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
BEEN PROVIDED TO THE WS NNER
SIGNATURE OF C
BRIAN THOMAS
07/16/10
TIFIED WELL CONTRACTOR 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