382032_Well Construction - GW1_20100331

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3083
1 WELL CONTRACTOR
John L. Boone
Well Contractor (Individual) Name
Spectrum -Nationwide Environmental. Inc.
Well Contractor Company Name
117 Sylvania Avenue
Street Address
Charlotte N. C. 28205
City or Town State Zip Code
(704 ) 334-2164
Area code Phone number
2. WELL INFORMATION
WELL CONSTRUCTION PERMIT# MC-70001706
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3 WELL USE (Check One Box) Monitonng d Municipal/Public ❑
Industnal/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Imgation❑ Other ❑ (list use)
DATE DRILLED 3/18/10
4. WELL LOCATION.
7541 Lawyers Road 28227
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY Charlotte COUNTY Meck.
TOPOGRAPHIC / LAND SETTING (check appropriate box)
❑Slope ❑Valley pfFlat El Ridge ID Other
LATITUDE 35 ° 11 ' 53 6800 " DMS OR 3x xxxxxxxxx DD
LONGITUDE 80 ° 42
53 8000 " DMS OR 7x xxxxxxxxx DD
Latitude/longitude source 3PS [(Topographic map
(location of well must be shown on a USGS topo map andattached to
this form rf not using GPS)
5 FACILITY (Name of the business where the well is located )
I awvers Road Bantist Chung
Facility Name Facility ID# (if applicable)
7541 I awvers Road
Street Address
Charlotte N C 28227
City or Town State Zip Code
Vacilv 7hushma
Contact Name
75411 awvers Road
Mailing Address
Charlotte N Co 28227
City or Town State Zip Code
( 7041 668-9780
Area code Phone number
6. WELL DETAILS
a. TOTAL DEPTH: 18'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q/
c WATER LEVEL Below Top of Casing 10' 6"
(Use "+" if Above Top of Casing)
FT
/WV
ATURE O
3 Is 2 0 Qy 2
d. TOP OF CASING IS 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) METHOD OF TEST
f. DISINFECTION: Type Amount
• g WATER ZONES (depth)
Top 10' 6" Bottom 18' Top Bottom
. Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING. Depth Diameter Weight Material
Top 2" Bottom 8 Ft 1 inch sch 40 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Material Method
Top 4" Bottom 4 Ft Portland ce Dour
: Top 4' Bottom 6 Ft bentonite ch pour
• Top Bottom Ft
9. SCREEN: Depth Diameter Slot Size Matenal
Top 8' Bottom 18 Ft 1 in 10S in PVC
Top Bottom Ft in in
Top Bottom Ft in in
10. SAND/GRAVEL PACK:
Depth Size Material
• Top 6' Bottom 18 Ft #2 sand
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Description
4" / 12' Red cl
Red/br ifs�i1t ! !�
12' / 18' y' "
MAR 3 1 71110
/
12 REMARKS:
inrormation rrocessing Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15 C 2 , WELL CONS -U ION STANDARDS, AND THAT A COPY OF THIS
D •f.BEEN PRO fE• • THE WELL OWNER i
t OI I
30
C RT IED WELL CONTRACTOR D E
John L. Boone
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev 2/09