382172_Well Construction - GW1_20100331

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envii onment and Natural 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-13
STATE WELL PERMIT#pf applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring E Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 03/11/10
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION
CITY CHARLOTTE
333 WEST 24TH STREET 28206
COUNTY MECKLENBURG
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑Flat DRidge ❑ Other
(check appropriate box)
LATITUDE
LONGITUDE
Latitude/longitude source
May be in degrees,
minutes, seconds or
in a decimal format
❑GPS Li 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 AT&T SERVICE CENTER
STREET ADDRESS 333 WEST 24TH STREET
CHARLOTTE
NC 28206
City or Town
State Zip Code
CONTACT PERSON AT&T SERVICE CENTER
MAILING ADDRESS
CHARLOTTE
City or Town
333 WEST 24TH STREET
NC
State
Area code - Phone number
5 WELL DETAILS
a. TOTAL DEPTH 21 0 FEET
28206
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing 13 0 FT
(Use "+" if Above Top of Casing)
3
I �d
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 Weiaht Material
From 0 0 To 11 0 Ft 2 INCH SCIi4o PVC
From To Ft
From To Ft
7. GROUT Depth Material Method
From 0 0 To 7 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8. SCREEN Depth Diameter Slot Size Material
From 11 0 To 21 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 9 0 To 21 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 21 0 TAN SILT
rr- r—rt Br—.rP.
rkL NQ..I V CUJ
v1AK gi 1 7n)n
Information Processing Unit
UVVU/ttOG
11 REMARKS
BENTONITE SEAL FROM 7 0 TO 9 0 FT
1 HEREBY CERT THAT THIS WEL �+S CONSTRUCTED IN ACCORDANCE WITH
CAC 2C, WE s NISI -RUCTION IfiDARDS, AND THAT A COPY OF THIS
E RDHAS BEE il•'0DTOT ELL OWNER
SIGNATURE OF CERTIFIED 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