384456_Well Construction - GW1_20100610

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natutal 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-31
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #Of applicable)
WELL USE (Check Applicable Box) Monitoring El Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery E Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05/25/10 - 05/28/10
TIME COMPLETED AM ❑ 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 ❑ Other
(check appropnate box)
LATITUDE
LONGITUDE
Latitude/longitude source
May be in degrees,
minutes, seconds or
in a decimal format
❑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 MANUFACTURING
STREET ADDRESS 2100 NORTH CHURCH STREET
CHARLOTTE
NC 28206
City or Town State Zip Code
CONTACT PERSON CLAIRE - SPRAYWAY
MAILING ADDRESS 1005 WESTGATE DRIVE
ADDISON IL
60101
City or Town State
( )-
Area code - Phone number
5. WELL DETAILS
a TOTAL DEPTH 46 5 FEET
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO in
c WATER LEVEL Below Top of Casing 20 0 FT
(Use "+" if Above Top of Casing)
ff d .P.;)
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 We I ht Material
From 0 0 To 31 5 Ft 2 INCH SCI-Y4o PVC
From To Ft
From To Ft
7 GROUT Depth Material
From 0 0 To 28 0 Ft Portland bentonite
From To Ft
From To Ft
Method
SLURRY
8 SCREEN Depth Diameter Slot Size Material
From 31 5 To 46 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 30 0 To 46 5 Ft
From To Ft
20-40 FINE SILICA SAND
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 1 0 GRAVEL
1 0 20 0 RED SILTY CLAY
20 0 34 0 BROWN SILTY CLAY
34 0 46 5 TAN SILTY CLAY
" V i ' 1 II 711111
''rLcassina Unit
v V V (.4/ri()G.
11 REMARKS
BENTONITE SEAL FROM 28 0 TO 30 0 FT
I DQ.t1EBEBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
WELL CONSTRUCTION STANP,' RDS AND THAT A COPY OF THIS
?RaAS BFW,j4 ROVIDED TO T '�..L,, OWNER
AC .
SIGNATURE OF CERTIFIED WELL CONTRACTOR
BRIAN THOMAS
06/02/10
DATE
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-1 b
Rev 7/05

C