380987_Well Construction - GW1_20100205

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Envuonment 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 #0( applicable) MW-10
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring El Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 01/19/10 - 01/22/10
TIME COMPLETED AM 0 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 0 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 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 25 5 FEET
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO EJ
c WATER LEVEL Below Top of Casing 18 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) 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 Wgr ht Material
From 0 0 To 15 5 Ft 2 INCH SCI-T4o PVC
From To Ft
From To Ft
7. GROUT Depth Material Method
From 0 0 To 11 5 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 15 5 To 25 5 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 5 To 25 5 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 25 5 TAN SILTY CLAY
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11 REMARKS
BENTONITE SEAL FROM 11 5 TO 13 5 FT
Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
A CAC WELL CONSTRUCTION ST RDS, AND THAT A COPY OF THIS
RE S BE&AJ. ROVIDED TO T EL OWNER
01/29/10
4A.W"%.
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