384227_Well Construction - GW1_20100603

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natut 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) VEW-11
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring II Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05/17/10 - 05/18/10
Recovery ❑ Injection ❑
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE COUNTY MECKLENBURG
3930 GLENWOOD DRIVE 28208
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑ Flat ERidge ❑ 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 FORMER UNIVAR
STREET ADDRESS 3930 GLENWOOD DRIVE
CHARLOTTE
NC 28208
City or Town
CONTACT PERSON
MAILING ADDRESS
State
UNIVAR USA, INC
Zip Code
17425 NE UNION HILL ROAD
REDMOND WA
98052
City or Town State Zip Code
Area code - Phone number
5. WELL DETAILS
a TOTAL DEPTH 20 0 FEET
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
c WATER LEVEL Below Top of Casing 0 0 (DRY) FT
(Use "+" if Above Top of Casing)
2
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 NIA
g WATER ZONES (depth)
From To From To
From To From To
From To From To
6 CASING Thickness/
Depth Diameter Weight Material
From 0 0 To 10 0 Ft 2 INCH SUN40 PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 0 To 3 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 10 0 To 20 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 7 0 To 20 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 SILTY CLAY
10 0 20 0 TAN SILT
3
l,irorn>nr.0 20/0
" /'r
11 REMARKS �'W OC` s..,
BENTONITE SEAL FROM 3 0 TO 7 0 FT/Oc Unrt
I DO HEREBY CERTIFY THAT THIS WELL CONSTRU<D IN ACCORDANCE WITH
15 AC 2C WELL STRUCTION ST RDS AND TT.,,,,, COPY OF THIS
RD HAS BEEN '(t.VIDEp TO THEOWNER.OWNER
4j£. ; _ ' f- , ;;-�� 05/25/10
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

7;17-ti
l_f_na_ hr.