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HomeMy WebLinkAbout386779_Well Construction - GW1_20100827NONRESIDENTIAL WELL CONSTRUCTION RECORD North Carolina Department of Environment and Natut al 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-20 STATE WELL PERMIT#(if applicable) DWQ or OTHER PERMIT #(if applicable) WELL USE (Check Applicable Box) Monitoring ® Municipal/Public ❑ Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑ Irrigation❑ Other ❑ (list use) DATE DRILLED 08/09/10 TIME COMPLETED AM ❑ PM ❑ 3 WELL LOCATION CITY CHARLOTTE COUNTY MECKLENBURG 6020 WILKINSON BLVD 28208 (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 if not using GPS) 4 FACILITY- is the name of the business where the well is located FACILITY ID #(if applicable) NAME OF FACILITY FMR MARATHON GAS STATION STREET ADDRESS 6020 WILKINSON BLVD CHARLOTTE NC 28208 City or Town State Zip Code CONTACT PERSON VIJAY KAVURI MAILING ADDRESS 6020 WILKINSON BLVD CHARLOTTE NC 28208 City or Town State ( )- Area code - Phone number 5 WELL DETAILS a TOTAL DEPTH 30 0 FEET Zip Code b DOES WELL REPLACE EXISTING WELL? YES ❑ NO c WATER LEVEL Below Top of Casing 20 0 FT (Use +" if Above Top of Casing) 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) NA' 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 Wg ia lit Material From 0 0 To 15 0 Ft 2 INCH SCH'4o PVC From To Ft From To Ft 7 GROUT Depth Material Method From 0 0 To 11 0 Ft Portland bentonite SLURRY From To Ft From To Ft 8 SCREEN Depth Diameter Slot Size Material From 15 0 To 30 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 13 0 To 30 0 Ft 20-40 FINE SILICA SAND From To Ft From To Ft 10 DRILLING LOG From To Formation Description 0 0 0 5 ASPHALT 0.5 10 GRAVEL 1 0 10,0 RED/BROWN CLAY 10 0 30 0 TAN SILTY CLAY 11 REMARKS BENTONITE SEAL FROM 11 0 TO 13 0 FT I DO HE-; . CE'�'TIFY THAT ' IS WELL W Yf ONSTRUCTED IN ACCORD N9E,WIT 15A NC •. •.C_t ---' '"UCTION . ;,,rFit • : DS N T,+A� PY,OF�`THI . RECORn�p"1TB`EN'.IDEDTOTHEv�� Ii zy`-,�Ctit rye' /11D SIGNATURE OF CERTIFIED WELL CONTRig0 2 JOHNNY BURR irf-Irmattnn Processing Unit PRINTED NAME OF PERSON CONSTRUCTINGokiE;WEt4U 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 (919) 733-7015 ext 568 Form GW-lb Rev 7/05 ''`.,...M