387950_Well Construction - GW1_20101013

3
1 WELL CONTRACTOR
John L. Boone
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3083
Well Contractor (Individual) Name
Spectrum -Nationwide Environmental. Inc.
Well Contractor Company Name
117 Sylvania Avenue
Street Address
Charlotte N. C. 28205
City or Town
(704 ) 334-2164
Area code Phone number
2 WELL INFORMATION:
WELL CONSTRUCTION PERMIT# MC-70001706
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) M/W 1 A
3. WELL USE (Check One Box) Monitonng rir Municipal/Public ❑
Industnal/Commercial ❑ Agricultural ❑ Recovery D Injection ❑
Imgation❑ Other ❑ (list use)
DATE DRILLED 9/7/10
4 WELL LOCATION.
7541 Lawyers Road
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
CITY Charlotte. N. C. 28227 couNTY Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope [Valley Q(Flat ❑ Ridge ❑ Other
LATITUDE 35
°11
LONGITUDE 80 42
53 6600 "DMS OR 3X XXXXXXXXX DD
53 8000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source WUPS propographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5 FACILITY (Name of the business where the well is located )
I awvers Road Baptist Churn
Facility Name Facility ID# (if applicable)
7541 I awvers Road
Street Address
Charlotte N_C_o 28227
City or Town
Vaciiv 7hushma
State Zip Code
Contact Name
7541 I awvers Road
Mailing Address
Charlotte N_C_ 28227
City or Town State Zip Code
( 704b 668-9780
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH. 18'
b DOES WELL REPLACE EXISTING WELL? YES Di NO ❑
c. WATER LEVEL Below Top of Casing 16' 7" FT
(Use "+" if Above Top of Casing)
3°3795.'
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 16' 7" Bottom 18
Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING Depth Diameter Weight Material
Top 3" Bottom 8
Top Bottom
Top Bottom
8 GROUT Depth
Top 5" Bottom 4
Top 4' Bottom 6
Top Bottom Ft
• 9. SCREEN: Depth
Top 8' Bottom 18
Top Bottom
Top Bottom
. 10. SAND/GRAVEL PACK.
Depth
: Top 6' Bottom 18
Top Bottom
Top Bottom Ft
11 DRILLING LOG
Top Bottom
Ft
Ft
Ft
Material
Ft Roanoke ce
Method
pour
Ft bentonite ch pour
Diameter Slot Size Material
Ft 2 in 10S in PVC
Ft in in
Ft in in
Size Material
Ft #2 sand
Ft
Formation Description
0 / 6" topsoil
6' / 8' red clay
8' / 18' tan/red clay silt
12. REMARKS:
-Groundwater marritoring-weIFIWW-fAirtstatied-
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A�. C 2C, WELL CONS UCTJSTANDARDS, AND THAT A COPY OF THIS
. R H BEEN PROMED 1()/HE WELL OWNER
11 — /0
ATURE OF CERTIFIED WELL CONTRACTOR 'DA1rE
John L. Boone
• PRINTED NAME OF PERSON CONSTRUCTING THE WELL
OLT 1 3 2010
Fort GW-1 b
Submit within 30 days of completion to: Division of Water Quality - Information Processing, InformatioRarc sing Unit
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] DWQ/BOG
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