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HomeMy WebLinkAbout384186_Well Construction - GW1_20100603NONRESIDENTIAL WELL CONSTRUCTION RECORD3 C. 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 STATESVILLE 176 COMMERCE BLVD NC 28625 City or Town State Zip Code ( 704 )- 872-7686 Area code- Phone number 2. WELL INFORMATION SITE WELL ID #(if applicable) RWP-3 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 05/17/10 - 05/19/10 TIME COMPLETED AM ❑ PM ❑ 3 WELL LOCATION CITY CHARLOTTE 10102 ALBEMARLE ROAD 28227 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 Latitude/longitude source May be in degrees, minutes, seconds or in a decimal tormat ❑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 WILGROVE EXPRESS STREET ADDRESS 10102 ALBEMARLE ROAD CHARLOTTE NC 28227 City or Town State Zip Code CONTACT PERSON IRVIN PERRY MAILING ADDRESS 6727 WILGROVE MINT HILL ROAD CHARLOTTE NC 28277 City or Town State Zip Code ( )- Area code - Phone number 5. WELL DETAILS a TOTAL DEPTH 55 0 FEET b DOES WELL REPLACE EXISTING WELL? YES ❑ NO E c WATER LEVEL Below Top of Casing 15 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 Weialit Material From 0 0 To 45 0 Ft 2 INCH SCI-Y4o PVC From To Ft From To Ft 7 GROUT Depth Material Method From 0 0 To 40 0 Ft Portland bentonite SLURRY From To Ft From To Ft 8. SCREEN Depth Diameter Slot Size Material From 45 0 To 55 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 43 0 To 55 0 Ft 20-40 FINE SILICA SAND From To Ft From To Ft 10 DRILLING LOG From To Formation Description 0 0 11 0 GRAVEL/ASPHALT 11 0 21 0 RED SILTY CLAY 21 0 34 0 BROWN SILTY CLAY 34 0 50 0 TAN SILTY CLAY 50 0 55 0 PARTIALLY WEATHERED ROCK '�D JUAi 0 �' znjg fnformab 11 REMARKS /� n processa BENTONITE SEAL FROM 40 0 TO 43-ft/Rryr 119 11nit i DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS �' RECORD AS BEEN PROVIDED TO THE W OWNER / 05/25/10 SIGNATUI�E�IFIED EL 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. (919) 733-7015 ext 568. Form GW-lb Rev 7/05 b mar L Poi E--(1