380989_Well Construction - GW1_20100205

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural 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)
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring E Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 01/19/10 - 01/22/10
MW-11D
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION
CITY CHARLOTTE COUNTY MECKLENBURG
2100 NORTH CHURCH STREET 28206
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑Valley ❑ Flat ❑ Ridge ❑ Other
(check appropnate box)
LATITUDE
LONGITUDE
Latitude/longitude source
May be in degrees,
minutes, seconds or
in a decimal format
❑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 CLAIRE MFG, INC
STREET ADDRESS 2100 NORTH CHURCH STREET
CHARLOTTE
NC 28206
City or Town State Zip Code
CONTACT PERSON CLAIRE-SPRAYWAY, INC
MAILING ADDRESS 1005 WESTGATE AVENUE
ADDISON IL 60101
City or Town State Zip Code
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 67 0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 47 0 FT
(Use "+" if Above Top of Casing)
ry 9
eB , c, ram,
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 Weight Material
From 0 0 To 52 0 Ft 2 INCH SCI-Y40 PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 0 To 48 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 52 0 To 67 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 67 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10. DRILLING LOG
From To Formation Description
0 0 1 0 GRAVEL
1 0 12 0 RED SILTY CLAY
12 0 35 0 TAN SILTY CLAY
35 0 50 0 BROWN SILTY CLAY
50 0 67 0 PARTIALLY WEATHERED ROCK
"A_- _Kp 7,f,'.=.0
FEB 1
1 2010
I/:rIn�Cs,
lrl ,,:lot, r,r aor `- c iViV
oc ��Ini Ll tit
it REMARKS
BENTONITE SEAL FROM 48 0 TO 50 0 FT
1 nn HFREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NC 2C WELL CONSTRUCTION ST DARDS AND THAT A COPY OF THIS
HAS.EEN PROVIDED T LL OWNER
ALCM,,`. ` 01/29/10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
BRIAN THOMAS
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