380022_Well Construction - GW1_20100104

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolma 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
3 i i'' 0
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
Street Address g. WATER ZONES (depth)
Charlotte N. C. 28205 Top 16' 8" Bottom 30 Top Bottom
City or Town State Zip Code Top Bottom Top Bottom
(704 ) 334-2164 Top Bottom Top Bottom
Area code Phone number Thickness/
2. WELL INFORMATION: 7 CASING. Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top 4" Bottom 10 Ft 2 inch sch 40 PVC
OTHER ASSOCIATED PERMIT#(if applicable) MC-70001706
SITE WELL ID #(rf applicable) MAN 1
3 WELL USE (Check One Box) Monitonng DI Municipal/Public ❑
Industnal/Commercial 0 Agricultural 0 Recovery ❑ Injection ❑
Imgation❑ Other 0 (list use)
DATE DRILLED 12/8/09
4 WELL LOCATION:
7541 Lawyers Road 28227
(Street Name, Numbers, Community, Subdiwsion, Lot No , Parcel, Zip Code)
CITY Charlotte cowry Mecklenburg
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑ Slope ❑ Valley VrFlat ❑ Ridge ❑ Other
LATITUDE 35 ° 11 •53 6600 "DMS OR 3X.XC000X)00(X DD
LONGITUDE 80 ° 42 53 8000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source 3PS Dropographic 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 )
L awvers Road Baptist Chufn
Facility Name Facility ID# (if applicable)
7541 I awvers Road
Street Address
Charlotte N C. 28227
City or Town State Zip Code
Vacily 7hushma
Contact Name
7541 1 awvers Road
Mailing Address
Charlotte N C 28227
City or Town State Zip Code
( 7041 668-9780
Area code Phone number
6. WELL DETAILS.
a. TOTAL DEPTH: 30'
b DOES WELL REPLACE EXISTING WELL? YES Cif NO ❑
c. WATER LEVEL Below Top of Casing 16' 8" FT
(Use "+" if Above Top of Casing)
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal
Top 6" Bottom 6' Ft Portland ce pour
Top 6' Bottom 8' Ft bentonite ch pour
Top Bottom Ft
9. SCREEN: Depth
Top 10' Bottom 30
Top Bottom
Top Bottom
Diameter Slot Size
Ft 2 in 108 in
Ft in in
Ft in in
Method
Material
PVC
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 8' Bottom 30 Ft #2 sand
• Top Bottom Ft
. Top Bottom Ft
11 DRILLING LOG
Top Bottom
8" / 8'
8' / 20'
20' / 30'
12. REMARKS:
Formation Descnption
red clay
tan/red clay silt
red/brown clay silt
Rr, t.d F 1 " —
JAN — 4 Zu I
Information Proces""
DWurDC,0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15 C C 2C WELL CONSTR TION STANDARDS, AND THAT A COPY OF THIS
R r H S BEEN PRONID D O THE WELL OWNER
SI ATURE OF CERTTF"IED WELL CONTRACTOR i DATE
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