386780_Well Construction - GW1_20100827

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 #(i( applicable) MW-21
STATE WELL PERMIT#(i( 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
6020 WILKINSON BLVD 28208
COUNTY MECKLENBURG
(Street Name, Numbers, Community, Subdivision Lot No , Parcel Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑Flat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE _
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal tormat
Latitude/longitude source ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form "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
CONTACT PERSON VIJAY KAVURI
Zip Code
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 El
c WATER LEVEL Below Top of Casing 20 0 FT
(Use "+" if Above Top of Casing)
33 7 8O
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 5C1W i lit Material
From 0 0 To 15 0 Ft 2 INCH �40 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 1 0 GRAVEL
1 0 10 0 RED/BROWN CLAY
10 0 30 0 TAN SILTY CLAY
Ir
f"acr"" e L
Amt, 9, 7 20i0
''nFt
11 REMARKS IniormatiDrrQIBOGa
BENTONITE SEAL FROM 11 0 TO 13 0 FT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A N. C 2C WELL CONSTRUCTION S ? DARDS AND THAT A COPY OF THIS
REC,'t HA) BEEN PR • IDEDTOTHr;J4 LLOWNE■R_Vif/'
��. �08/11/10
ATUR:[• CERTIFIED WELL CONTRACTOR 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

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