386031_Well Construction - GW1_20100803

3 G31
NONRESIDENTIAL 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-10-D, S
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring
Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery E Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 07/06/10 - 07/08/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
5315 MONROE ROAD 28205
COUNTY MECKLENBURG
(Street Name, Numbers, Community Subdivision Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑Valley ❑ Flat ❑Ridge ❑ Other
(check appropriate 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 rf not using GPS)
4 FACILITY- is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY A CLEANER
STREET ADDRESS 5315 MONROE ROAD
CHARLOTTE
NC 28205
City or Town
CONTACT PERSON
MAILING ADDRESS
State
NCDENR
Zip Code
601 OBERLIN ROAD
CHARLOTTE NC
28205
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 50 0/25 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL/ YES ❑ NO
c WATER LEVEL Below Top of Casing 9 0 FT
(Use "+" if Above Top of Casing)
RECEIVED
AUG 0 3 2010
Information Processing Unit
DWQ/BOG
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 NIA Amount N/A
g WATER ZONES (depth)
From To From To
From To From To
From To From To
6 CASING Thickness/
Depth Diameter We i ht Material
From 0 0 To 45 0 Ft 1 INCH SCR'40 PVC
From 0 0 To 10 0 Ft 1 INCH SCH 40 PVC
From To Ft
7 GROUT Depth Material Method
From 0 0 To 4 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 45 0 To 50 0 Ft 1 0 in 010 in PVC
From 10 0 To 25 0 Ft 1 0 in 010 in PVC
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 42 0 To 50 0 Ft 20-40 FINE SILICA SAND
From 8 0 To 25 0 Ft 20-40 FINE SILICA SAND
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 10 0 RED/ORANGE SANDY CLAY
10 0 28 0 TAN SILTY CLAY
28 0 50 0 TAN WEATHERED ROCK
11 REMARKS
BENTONITE SEAL FROM 28 0 TO 42 0 FT & 4 0 TO 8 0 FT
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC'2C WELL CONSTRUCTION STANDA-+S AND THAT A COPY OF THIS
RECOR i Eftd'P*EDTOTHE WE _y NER
r r`.r ` y. nre /12/10
SIG ATURE OF CERTIFIED WELL CONTRACTO DATE
JOHNNY BURR
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