381370_Well Construction - GW1_20100301

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depai tment of Environment and Natui al Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2579
1. WELL CONTRACTOR
DANNY SUMMERS
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-4
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring El Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 02/19/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
COUNTY MECKLENBURG
6441 NORTH TRYON STREET 28213
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑Valley ❑ Flat ❑Ridge ❑ Other
(check appropnate 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 FMR CIRCLE K - 8402 (PARKS CHEVROLET)
STREET ADDRESS 6441 NORTH TRYON STREET
CHARLOTTE NC 28213
City or Town State
CONTACT PERSON NCDEHNR
Zip Code
MAILING ADDRESS 601 OBERLIN ROAD
RALEIGH NC
27605
City or Town State
( )-
Area code - Phone number
5. WELL DETAILS
a TOTAL DEPTH 25 0 FEET
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ln
c. WATER LEVEL Below Top of Casing 12 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 To From To
From To From To
From To From To
6 CASING Thickness/
Depth Diameter Weiqht Material
From 0 0 To 10 0 Ft 2 INCH SCR 4o PVC
From To Ft
From To Ft
7. GROUT Depth Material Method
From 0 0 To 6 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8. SCREEN Depth Diameter Slot Size Material
From 10 0 To 25 0 Ft 2 0 in 010 in PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 8 0 To 25 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 10 0 RED CLAYEY SILT
10 0 25 0 TAN SILT
ocr,coo. irmn
L '0 L®'c..J' P. ti V tt,..— I.,-,f'
MAR g iiliLI
.l mar nia uUu riUl.l;:,5t-ir i
rttAit-Nta
vv
11 REMARKS
BENTONITE SEAL FROM 6 0 TO 8 0 FT
I DO HEREBY CERTIFY THAT THIS WELL WAS ONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STAND S, AND THAT A COPY OF THIS
RECORD HAS BEEN PRO' LIED TO THE WE WNER
f•
r --- 02/22/10
SIGNATU 2E"OFCERTIFIED WELL CONTRACTOR DATE
DANNY SUMMERS
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