384208_Well Construction - GW1_20100101

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nattu 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
( 704 )_ 872-7686
State
Zip Code
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) MW-24
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring E Municipal/Public ❑
Industrial/Commercial ❑ Agricultural D Recovery ❑ Injection ❑
IrrigationD Other ❑ (list use)
DATE DRILLED 05/25/10 - 05/26/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY ASHEVILLE COUNTY BUNCOMBE
22 CHURCH STREET 28801
(Street Name, Numbers, Community Subdivision
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE _
LONGITUDE
Lot No , Parcel, Zip Code)
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 SWANNANOA LAUNDRY
STREET ADDRESS 22 CHURCH STREET
ASHEVILLE
NC 28801
City or Town State
CONTACT PERSON NCDENR
Zip Code
MAILING ADDRESS 601 OBERLIN ROAD
RALEIGH NC
27699
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 45 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO In
c WATER LEVEL Below Top of Casing 37 0 FT
(Use +" if Above Top of Casing)
3
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 Weight Material
From 0 0 To 25 0 Ft 2 INCH SCI-T4o PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 0 To 21 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 25 0 To 45 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 23 0 To 45 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 25 0 BROWN/RED CLAYEY SILT
25 0 50 0 TAN SILT
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11 REMARKS
ni,v 'Oc-
BENTONITE SEAL FROM 21 0 TO 23 0 FT..,,-, 3etgrr r ,
` ws - —r 0/t
I DO HEREBY CERTIFY THAT THIS WELL WA CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C WELL COVSTRUCTION STAN5Y;- JRDS AND THAT A COPY OF THIS
REC HAS BEEN PR DED TO THE we,kr OWNER
P... -.. 05/26/10
SIGNATURE"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
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