387150_Well Construction - GW1_20100928

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natwal 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) BR-22
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring El Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 09/15/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
COUNTY MECKLENBURG
1000 SOUTH CEDAR STREET 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 DGPS ❑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 BEAZER PROPERTY
STREET ADDRESS 1000 SOUTH CEDAR STREET
CHARLOTTE
NC 28208
City or Town State
CONTACT PERSON CLARKSON STREET, LLC
Zip Code
MAILING ADDRESS 401 SOUTH TRYON STREET
CHARLOTTE NC
28202
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH
62 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO Fj
c WATER LEVEL Below Top of Casing 35 0 FT
(Use +" if Above Top of Casing)
3
M
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 Wg 1qlit Material
From 0 0 To 52 0 Ft 2 INCH SCH'40 PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From To Ft
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 52 0 To 62 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 50 0 To 62 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 22 0 TAN SANDY ROCKY BACKFILL
22 0 35 0 RED SILTY CLAY
35 0 62 0 TAN/BROWN/YELLOW HARD SANDSTONE
11 REMARKS
TEMPORARY WELL - WELL ABANDONED AFTER SAMPLING
1 DO HERE:Y CERTIFY THAT THIS WELL W ONSTRUCTED IN ACCORDANCE WITH
15A NCAW LL CONST CTION STA, • RDS AND THAT A COPY OF THIS
RECOR er(- , •>^ , EDTOTH: 7W'R
glif 09/20/10
SIrNATURE 0- ERTIFIED WELL CONTRACTOR DATE
JOHNNY BURR
PRINTED NAME OF PERSO4to.il VinCTONTItEtATLL
Submit the original to the Division of Water Quality within 30 days. Attn Information MgiE p 2 8 2010 Form GW-lb
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No [phone] ext 568 Rev 7/05
Information Processing Unit
1-1W0/90,

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