384186_Well Construction - GW1_20100603

NONRESIDENTIAL 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
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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. [phone] ext 568.
Form GW-lb
Rev 7/05

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