380950_Well Construction - GW1_20100101

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3098
1 WELL CONTRACTOR
JOHNNY BURR
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-1
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring E Municipal/Public D
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 01/21/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY ASHEVILLE COUNTY BUNCOMBE
44 CAROLINA AVENUE 28801
(Street Name, Numbers, Community Subdivision, Lot No Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope DValley ❑ Flat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE
LONGITUDE
May be in degrees
minutes, seconds or
in a decimal format
Latitude/longitude source ❑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 MINICO-KARR
STREET ADDRESS 44 CAROLINA AVENUE
ASHEVILLE
NC 28801
City or Town State Zip Code
CONTACT PERSON NCDEHNR
MAILING ADDRESS
RALEIGH NC 27605
City or Town State Zip Code
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 30 0 FEET
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO E
c WATER LEVEL Below Top of Casing 23 0 FT
(Use +" if Above Top of Casing)
601 OBERLIN ROAD
�3 , A6
, 0 r, 0
� �
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 W I lit
From 0 0 To 20 0 Ft 2 INCH S�tf40
From To Ft
From To Ft
7 GROUT Depth Material
From 0 0 To 11 0 Ft Portland bentonite
From To Ft
From To Ft
Material
VC ial
Method
SLURRY
8 SCREEN Depth Diameter Slot Size
From 20 0 To 30 0 Ft 2 0 in 010 in
From To Ft in in
Material
PVC
From To Ft In in
9 SAND/GRAVEL PACK
Depth
From 17 0 To 30 0
From
From
Size
Ft 20-40
Material
FINE SILICA SAND
To Ft
To
10 DRILLING LOG
From
00
03
07
10
40
20 0
To
03
07
10
40
20 0
30 0
Ft
Formation Description
ASPHALT
CONCRETE
GRAVEL
RED CLAY
TAN SILTY CLAY
GRAY SILT
ir"���b�
- 9 1..A
�l O�Mt t ..C1nteq � unit
Won plow:`
tt „�
11 REMARKS
BENTONITE SEAL FROM 11 0 TO 17 0 FT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL��C��O�NN TRUCTION STD " IARDS AND THAT A COPY OF THIS
RECORRH4fS 6EEN EB 'IDED TO TH :>a,/LL OWNER
SIGNATURF CERTIFIED LL CONTRACTOR DATE
01/27/10
JOHNNY BURR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 daysAA' , Srmation Mgt ,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No [phone] ext 568
FEB0 7 2013
Form GW-lb
Rev 7/05

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