384176_Well Construction - GW1_20100603

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) MW-16
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ® Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 04/14/10 - 04/15/10
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION
CITY CHARLOTTE
4669 FARM POND LANE 28212
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 decunal 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 SNO-WHITE CLEANERS
STREET ADDRESS 4669 FARM POND LANE
CHARLOTTE
NC 28212
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 19 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
c. WATER LEVEL Below Top of Casing 6 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 Weight Material
From 0 0 To 4 0 Ft 2 INCH SCCH4o PVC
From To Ft
From To Ft
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 4 0 To 19 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 3 5 To 19 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 4 0 BROWN SILTY CLAY
4 0 8 0 RED SILTY CLAY
8 0 19 0 TAN SILTY CLAY
1ACUM"1"0 L
JUN 0 3 2010
liT'fIldtton Nrocess ng Unit
11 REMARKS DWQ/BOG
BENTONITE SEAL FROM 3 0 TO 3 5 FT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
CA WELL CONSTRUCTION STAND RDS AND THAT A COPY OF THIS
REV AS BEEN PROVIDED TO T OWNER
J7Al�� 04/27/10
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

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