384191_Well Construction - GW1_20100603

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depat tment of Environment 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 #(if applicable) SVEP-4
STATE WELL PERMIT#Of applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring E Municipal/Public ❑
Industrial/Commercial ❑ Agricultural In Recovery ❑ Injection ❑
Irrigation❑ Other in (list use)
DATE DRILLED 05/17/10 - 05/19/10
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION
CITY CHARLOTTE COUNTY MECKLENBURG
10102 ALBEMARLE ROAD 28227
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope ❑Valley In Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source ❑GPS El 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
CONTACT PERSON IRVIN PERRY
Zip Code
MAILING ADDRESS 6727 WILGROVE MINT HILL ROAD
CHARLOTTE NC
28277
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH
13 5 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO E
c WATER LEVEL Below Top of Casing 0 0 (DRY) FT
(Use "+" if Above Top of Casing)
ct
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 W t ht Material
From 0 0 To 3 5 Ft 2 INCH SLtT4 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 3 5 To 13 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 3 5 To 13 5 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 13 5 RED SILTY CLAY
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11. REMARKS
BENTONITE SEAL FROM 3 0 TO 3 5 FT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
ORD HA BEEN PROVIDED TO THE W WNER
05/25/10
S R ED L O TOR 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 Mad Service Center— Raleigh, NC 27699-1617 Phone No [phone] ext 568.
Form GW-1 b
Rev 7/05