380759_Well Construction - GW1_20100205

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natut al Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2581
1. WELL CONTRACTOR
BRIAN THOMAS
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-7
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring E Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 01/08/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
COUNTY MECKLENBURG
1200 CHARLOTTETOWN AVENUE 28204
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑Valley ❑ FIat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source EGPS ❑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 DOUGLAS FURRIER
STREET ADDRESS 1200 CHARLOTTETOWN AVENUE
CHARLOTTE
NC 28204
City or Town State
CONTACT PERSON NCDEHNR
Zip Code
MAILING ADDRESS 601 OBERLIN ROAD
RALEIGH NC
27605
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH
25 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top of Casing 15 0 FT
(Use "+" if Above Top of Casing)
3'80759
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.
From 0 0 DToth10 0 Ft 2 INCHer
From To Ft
From To Ft
Thickness/
Sc�i�a6 Material
7. GROUT Depth Material Method
From 0 0 To 3 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8. SCREEN Depth Diameter Slot Size Material
From 10 0 To 25 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 8 0 To 25 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
00 10 GRAVEL
10
12 0 RED SILTY CLAY
120 250
TAN SILTY CLAY
RECERIEr
FEB 0t:'',-to
Information Prc�ccsmg
DWQ/Rrw
11. REMARKS
BENTONITE SEAL FROM 3 0 TO 8 0 FEET
ERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
ELL CONSTRUCTION STA S AND THAT A COPY OF THIS
EEN-PROVIDED TO TH AL NER
AA..
SIGNATURE OF CERTIFIED WELL CONTRACTOR
BRIAN THOMAS
/12/10
DATE
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