389512_Well Construction - GW1_20101119

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 258o
1. WELL CONTRACTOR
JASON MANTAK
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD
STATESVILLE NC
28625
City or Town State Zip Code
( 704 )- 872-7686
Area code- Phone number
2. WELL INFORMATION
SITE WELL ID #(if applicable) MW-19
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ® Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/14/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
11407 GRANITE STREET 28273
COUNTY MECKLENBURG
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source ❑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 SEARS FACILITY - 8075
STREET ADDRESS 11407 GRANITE STREET
CHARLOTTE
NC 28273
City or Town State
CONTACT PERSON OFFICE ENVIRONMENTS
Zip Code
MAILING ADDRESS 11407 GRANITE STREET
CHARLOTTE
City or Town
( )-
Area code - Phone number
5. WELL DETAILS
a. TOTAL DEPTH
NC
State
100 0 FEET
b DOES WELL REPLACE EXISTING WELL
c. WATER LEVEL Below Top of Casing 12 0
(Use "+" if Above Top of Casing)
28273
Zip Code
YES❑ NO®
FT
3
r
d TOP OF CASING Is 0 0 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e. YIELD (gpm) N/A METHOD OF TEST N/A
f DISINFECTION Type N/A
g WATER ZONES (depth)
From To From
From To From
From To From
6 CASING
From 0 0
Depth
To
90 0
From 0 0 To 40 0
From
Ft
Ft
To Ft
7. GROUT Depth
From 0 0 To 84 0
From 0 0
To 40 0
From To
8 SCREEN
From
From To
From To
9 SAND/GRAVEL PACK
Depth
From 88 0
To 100 0
From To
From To
10 DRILLING LOG
From To
00 50
50 120
120 210
21 0 100 0
Ft
Ft
Ft
Amount N/A
2 IINCHer
6 INCH
To
To
To
Thickness/
SCR'40 PMaterial
SCH 40 PVC
Material
Portland bentonite
Portland bentonite
Method
SLURRY
SLURRY
Depth Diameter Slot Size Material
90 0 To 100 0 Ft 2 0 in 010 in PVC
Ft in in
Ft in in
Size Material
Ft 20-40 FINE SILICA SAND
Ft
Ft
Formation Description
BROWN CLAY
BROWN SANDY SILT
WEATHERED ROCK/BROWN SILT
WHITE/GRAY, ROCK.... 1
✓s,r 4� "Y' rtkeN' "
r-`.s1
Gyar�
V tG
N :1tla
1
11 REMARKS
BENTONITE SEAL FROM 84 0 TO 88 0 FT
I DO HEREBY CERTIFY THAT THIS WEL W
15A NCAC 2rA. ELL CONSTRU
RECORD HEN PROV
NSTRUCTED IN ACCORDANCE WITH
RDS, AND THAT A COPY OF THIS
L OWNER
SIGNAT
JAS
•
10/19/10
E OF CERTIFIED WELL CONTRACTOR DATE
MANTAK
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